-,-,- 



CONGRESS, 





UNITED MUls 



June. 



nuKcJ. uVlA^ 



CLINICAL LECTURES 



DISEASES OF OLD AGE 



S BY 

J. M. CHARCOT, M.D.. 

Profemor la the Faculty of |f< IIm Balpltritw*; Ifonbar of t 

of Hi udoti ; of tl -ih : of the 

Natural SciouoM, BriUMela; l'»e».dent of the Aaui .. etc. 



TIIANSI.\TED BY 

LEIGE II. HINT. i:.s,.. M.D.. 

Ij»lM)rai- • in l'iitholugy la the Medical Di \.-w V..r' 



WITH ADDITIONAL | BT 

ALFRED L. LOOMIS, M.D., 

Micnt of the 
New Totft .. f ; 

to the Central Di*|»ea<ary: V i the Bcllevnc Il.^j.iul ; 

to the Monnt Sinai Ho>i>ital, etc., etc. 




NEW YORK 
W ILLI A M W O o I) . 6 O M P A X Y 

'27 Great Jones Btskei 
18S1 



^ 



i 






NOTE. 

XXL U arc those deli 

by Pro£ I y Prof. J. 

pond wil 

numbering in II.. and III., 

ectively, of 1 nfl renumbered t'» avoid con- 

fusion, 

1 Lth number XXI r. 

for the same iva>on. 

II. il. 



PREFACE. 



The few Lectures which I have been requested to add 

1 by Professor Charcot on Diseases of 

Old Age, embody, in the main, the salient points in Dis- 

»s of Advanced Life which I have been accustomed to 
impress upon my classes at my clinic in Bellevue Hospital. 

They are presented in this form with the hope that 
they may prove acceptable additions to the very inter- 
ing lectures of Professor Charcot N 

ALFRED L. LOOMIS. 

11 West Thiutt-fourtii Btb 'Kk. 



CONTEXTS 



INTBODUCTION. 

PAGE 

Empirical and Scientific Medicine — A Compari < n the Ancients and the 

1-10 



LECTUEE I. 

GENERAL CHARA< TILE PATHOLOGY. 

Objects of .1 from a Medi- 

ci] Poll '■ of 

iil«- Pathology — Pby _':ms 

an . 
tip 

culiar 1 1 ivus to the Greater Number oJ 



LECTURE II. 

TEH FEBRILE STATE IN Till: AGED. 

f Reaction in Old Acre — Organs seem to - rises 
— The G noticed— Fever in the Aged — What is 
Fever?- [mportanee of the Clinical Thermometer— Chill in Old People — 
Temperature u:\ r Pneumonia — The Practical Deduction! to be 
made therefrom— Defer . and Critical P« rturbations — Di6e;.- 
where the Temperature is Lowered iustead of Elevated 26-31 



LECTURE III. 

[JLAR RHEUMATISM /: muttons Noueux) AND GOUT, PATHOLOGICAL 
BLOOD-CONDITTO I )UT. 

Frequency of Chronic Articular Rheumatism in the Salp<trure — Its Resemblance 
to Gout — The Doctrine of Identity — Silence of the Physicians of Antiquity 
in this Regard— Necessity of taking up the Preliminary Study of Gout before 



VI 11 CONTENTS. 

PAGE 

that of Chronic Rheumatism — The Gouty Diathesis — Its General Characteris- 
tics— lieguiar and Irregular Gout— Acute and Chronic Gout — Pathological 
Blood-condition* of thia Affection — Gouty Co:. ite of 

Soda — Drio Acid'i Normal I. - of it in the 

Blood of the 'Jouty — The " Thre id "' Proc I not in Excess iu the 

Blood of Rheumatic i: 
with this Alteration — A ;»ood in 

at State of thfl e Gout during ti 
between thorn ; in Chronic Gout ... 



LECTURE IV. 

PATHOLOGICAL 

i of the rodial C 

log ice those Tiasuee 

m< 

Dry Irthritu Ad 

ni.iy I is 

( 'onon • 

> Tophni d 



I.i:< V. 

PATHOLOGICAL ' 

ELetrocedent Gout; io«t Instances after an 

Autt>i>s\ m ge e ■ 

ih- 
roochial 

Chan ■ nlm — 

Sinn 

the I re urs li. 



VI. 
SEMEIOLOGY OF GO 

The Two Prin I alwaya 

eul in Appeal 
Sym >toiuN 

but | 

allowing Acute 
Gout — Qont Chronic, from \l. welopmeut of ■ V4-00 



CONTENTS. IX 



LECTURE ViL 

SYMPTOMATOLOGY OF VISCERAL GOUT. 



Predilection of the Ancients for the Study of Pathological Metamorphosis — 
lui ;icism of the Moderns 

— I' .. G<»ut — Functional Dermi Lesions 

— Masked, M Retrocedent Goat — OsJD Gout exist Inde- 

pendently of all Articular of the Digestive (anal — 

gas— Dyspepsia, Cardialgia, Goaty i Bepatio 

Evident - of the Heart and 

;: - Its Intlu- 
eni' ira- 

tory Byatetn kathma -The Urinary Passage! I 1 1 of 

. the Kid- ■ N< plirn- 
IndieuUouoi: ■ .-eases whieh accompany Gout 01-71 



LECTURE VIII. 
00* vr DIB] iSBB OF 001 

Anthrax — Grave 
Phl< • as — Di no — Inti roar* 

rent Dieoasi I're- 

with. if 

ana 

In- 

tea Aasociut I in the 
and Cancel ; of Goat ajid Lh 72-80 



LECTURE IX. 

ETIOLOGY OF G< I 

Cottdittam 'iont — Suitable 

Follow in Making this Kind | ration [nconT e nienoa 

of ' hemical and 1 d Theories — 

- which have 
them — I! An- 

tiquity lease — Wr. Diminu- 

ti<- »— Modi- 

lo rlsbitl noes 

— .M llv in England and in 

- , — 
Almost wiu.i:. analytical Study <>f the Causes of 

ige Tempo- 
ral! Want of 

■ esses — Ferrntnted Liquors : Ale, 
Porter, \\ n.e, and i ider — Exciting 81-91 



APPENDIX TO LECTURE IX. 
English Beers 92-94 



x coxte:- 

LECTURE X. 

PATHOLOGY OF GOUT. 

Rational Theory of Gont — It can har<lly bo Formulated in tho Praeonl State 
of Scientific Knov. In- 

fluence of 

lisln - t that I . 

Patients —Origin <>f I 
— A i < 
menl n of Zali :} — Km 

- -ia 
ill the Oft] 

! our KnOWled rrt-seiit L>.. 



XI. 
CHRONIC ARTICULAR KB 

Ohionic; Articular III .-> of the 

tfalad, & 

Cbx< ' 

matistu - S 
the I 
terisl 

me ; in thi 



v.: : • , :■ - 



. 



I.i [I. 

OOKP&RIS 
OTl 

. AMU'OlN 

Analogy between the 

tism 

\\ th Exudation — The Intlami 

as of the Articular i 
poured our into ; 
of Chrouio Rheumnti 
from 

thritis Syj.liilit 
Ghron c Rheum 
Cau» 
— Chronic Rheumatism, in thi .»-115 



CONTEXTS. XI 



LECTURE XIII. 

ACUTE ARTICULAR RHEUMATISM CONSIDERED ESPECIALLY IX ITS RE- 
LATIONS WITH CHRONIC AETICULAB RHEUMATISM AND G> 

ription of Acute a :hcumatism— Analo- 
- with Chronio Rheumatism — Dill- r arating it from Goat — Acute 
nmatiam : fill- 
ing The 

i the Nun. 
— J iut, 

ami .Subacute Art.culur Rheumatism 1 10— 1~2 



i tiki: xiv. 

KRAI AFFECTIONS l' 

I 1 thor-o i • 

till 

tin the 

i 

Hi- 
ll 

— Astliii 
A 1 ' | 

] . 



LECTURE XV. 

BYMPTOMATOLOG BBONIC P» kBTIOULAB RHEUicA- 

nsii 

ic Articular Rheumatism — In Reality Con- 

ilar 

Kh< tly Confounded with <;■ 

from which i I in the Smaller 
Joi 

at the C< mmi 

of — l'ermam 



Xll 



CONTEXTS. 



— Pain— Crackling— Bony Deformities— Joints which are Preferably Affected 

— The Hands almost always the 1 Invasion — 

Mode of Succession of Cases of Arthr t ently 

Generalized from the Commencement — In OM -*ive 
Course — Consecutive Deform il 

Varieties- I rm— 

(Edematous Form- I -—Of 

the Vertebral Column — 1» i the 

Joints — Mode of Product: odic 

Contracti' I auses — G* neral 
Reaction— Rapid Development 






LECTURE XVI. 

SYMPTOMATOLOGY Of PARTIAL OHB0K CD OF HR- 

BBRDE3 



Partial 

i 

volv 

— Articular 1» I 

— Articular P 

: 

apanies the KliL-um . 

I 



locndi aeatt 



>«iues of 
the 

tie— 

though xcry ra. 



.VII. 



ETIOl 



The Principal Canst all the Forme 



of this Dis«a-<" 

and 1 

■ likewise i 

■ 

Chronio R 
Wei I 



tj 



.:* In- 
rr— The 



\ .• ■ 



< las 
■otioae — 
Btartoo — 

p 1 V.-h 

i$-l» 



CONTENTS. X1U 



LECTUEE XYIII. 

TREATMENT OF GOUT AND CHRONIC ARTICULAR RHEUMATISM. 

PAGE 

General Considerations Concerning the Treatment of Gout— Treatment of the 
Attacks or Paroxysms — The Expectant Plan — Quack Remedies- -Colehicum — 
Advantages and Disadvantages of this Agent — Rules which should Govern its 
Employment— Naro tia : BjCOOj a imM and Opium — Sulphate of Quintal — 
Iodide of rntiiinni Tlnntnin of Guaiacum — Topical Ben 

.jent of the Constitnl 

Various twam, Lithium — Action of t: ■ » — 

Oontraindioated — Mineral Waters — Tonics and 

machics — Treatment of the L .Ik-Stones and Rigidity 

of Joints— Treatment of Abnormal Gout— 1 meat of 

Chronic Articular 1 r Knowledge upon 

this Su urn. Sulphate of 

Qainia, Bloodletting — Alkalies — Tinotoie of lo<: tally and 

v — Tincture of Guaiacum — Iodide of Potassium — Ir I 

J Waters— Medical Art Fowerieai In the 
Majority I . 1 00- 1 80 



APPENDIX. 

CLIN! THERM IX OLD AGE.' 



tiki: xix. 



Importance of Clinical Thermometry in General — Its Aj to Senile 

PathoL . .! AL-idity Normal 

am: Patho- 
cal < 'ondi — Low, 
Linm. and High r from High Tern] 
wL :i ( .f Time B of the 
Dai nrenee — P).. I Expcriii.- 
from Lowering of the Temperature 166-170 



LEOTUBE XX. 

Thermal Characteristics of Febrile Diseases in Old " the 
Continu.d T\ -eases of the Remit • -Febrile I 
of tin- [ntermittenft Type- Rapi . • ntral Temperature, at thfl Time 
of Death, in Certain D I'. taniu 
— Hysteria — Cerebral Hemorrhage and Softening — Epileptiform and Apoplec- 
tiform Attacks H 



tures delivered by J. M. Charcot, in th< 
xx.. and xxi.. arei., ii.. and iii. of the Appendix, renumbered to avoid confusion. — 
L. H. ll.j 



xiv oosmai 

LECTURE XXI. 

Central Algidity — The Disagreement that ma Between the External and 
the Deep Pa 

— Cancer, Aneem in 

l of Drug- — 

ix. 

Peritonitis— D •■ 

Algid L'ufjuinouia- I -4-193 



.II.' 
SEN! I 
itomy— Symptoms— Etiology. 

;;i: win. 

Diagnosis— Prognosis — Treatment.. 900-906 

TI UK XX 

U. 
Terential Diagnosis— Progr.o-. 

i.i-:< xxv. 

toms— Differential Diagnosis — Prognosis — Treatment 

ui m 
LECTURE XXVI. 

Sympt agnosia— Prognosis— Treatment M S - W O 

ug Lectnrea are by Professor Alfred L. Looaaia, of 

Nan ^ 



CONTEXTS. X V 



LECTURE XXVII. 

* CEREBRAL HEMORRHAGE.— APOPLEXY. 

Moibid Anatomy — Ed Symptoms — Differential Diagnosis — Prognosis — 
ament — Cerebral Softening — Bai at — Morbid Anatomy— 1 
ology 881-837 

LECT! Will. 

CEREBRAL SOFTKN! 

Symptoms — Differential Diagn< >sis— Trt Atro- 

. —Morbid AnAtomj 

I Chmngei in tin- Alimi d! 

omj 

LECTURE XXIX. 

(HI: \TAKK1I 

•gnotui — '1 : 

LECTURE XI 

Constipation in <>M Aft ''rog- 

no.v mgea in tl- 

it >gnoaia— 1 

. -Morbid Anat« 

LECTURE XXXI. 
ilk BTPEBTBOPHI OF Tin: PB06TATS (.land. 

•>ras— Dilf. k— Dcfini- 

ti" -.iiny— Ku .ptoius — Differential 

• at 21 



CLINICAL LECTURES 



ON THE 



DISEASES OF OLD AGE. 



INTRODUCTION. 



EMPIRICAL AND BCIENTH vim 

a N < DENTS and Tin; HODBRNa 

y inaugurate is purpi i 
quaint you with tl thai distingui athology 

from that of adults, and to tix. y< 
which are mi I with in asylums i Cor the 

Within as close lu I by a method 

which is Buitahlel tacal instruction. We shall Dot, however, neglect 

the clinical aspect ; and I hope, indeed, to be abl • ;. at the 1" -1- 

. some of the types which i - of our descriptions 

You are dow acquainted with the obj< ei tidies ; and wi 

nt once commence with thi t, for I am of Condillao'a opinion, and I 

think thai considerations general in then 
than at its beginning. 

Still. th( 1 i>sic:d tradition, as it were, which pu1 

nnder the obligation to explain himself at the very commencement in a 
more or forical manner upon certain fundamental 

ion, to make a profession of hi iief. 

I do not think I ought to i Kempt myself from this obligation, and shall 
courageously enter upon ti plishment of this task— often thank 

always difficult — reckoning not a little upon your indulgence and upon the 

kindness which you have so often shown to D 

Ther 'tuple, and, so to speak, natural means of broaching these 

1 and important questions : it is to inquire as to how. in the court 
the progn ssive deTelopment of scientific culture, they have become known 

and how they have been settled; in this way 1;. comes a means of 

criticism. 

Now, in following that path, it will soon become very clear to you that 
pure observation was never attained at any epoch without supreme efforts 
having been made to prevail over the spirit of hypothesis. 



V CLINICAL LECTURES ON 

As for that which especially concerns medicine — and with this we are 
alone occupied here — even the most stoical minds have never confined them- 
selves to the mere statement of facts, but have sought to make a common 
bond of union between them by means of some theory. 

From the very commencement we see the mind of man occupied as 
much, nay more, with the subjective relationship of things than with their 
reality ; the data furnished empirically by observation, when still but re- 
cently obtained, are brought together in a class — tested, one by the others, 
in order that systems or theories may be derived from them. 1 

In this, it must be confessed, lies one of the necessities of the human 
mind, and, according to a celebrated saying of Kant's, it seems that our 
ideas are forced to cast themselves in this common mould ; and it was pre- 
cisely this which was recognized by the founder of positive philosophy him- 
self, who will undoubtedly be reproached by no one for having opened the 
way for hypothesis, when he declared that, even if a theory is to be founded 
entirely upon observation, it must still from sheer necessity be guided by 
some theory in order that it may yield to observation a profitable result. 

The real wants of our minds can, however, always be distinguished, in 
this connection, from the manifold exaggerations with which systematic 
thinkers allow themselves to become involved. Hence we see in reality the 
existence of a method of speculation which is grounded strictly upon facts, 
as well as the existence of a method of observation keeping aloof as much 
as possible from premature speculation ; and the whole question conse- 
quently resolves itself into the discovery of a common ground whereon 
these two methods can meet. 

Gentlemen, viewing matters from the point which we occupy to-day. I 
think that we can discover a radical difference between ancient and modem 
medicine. 

The first has always been deficient in those elements necessary to the 
construction of a positive theory, and for this reason the numerous attempts 
which it has made in that direction have of necessity signally failed. 
Modern medicine, on the other hand, possesses some of the matt rial that 
could serve such a construction ; but. profiting by the mistake made by its 
predecessors, it knows above all what paths should remain impervious to 
speculation, and it likewise knows what tracts it may survey without falling 
into error. 

I shall endeavor to develop this theme in the course of the present 
lecture ; but, first of all, we must be acquainted with that time in history 
when the old system of medicine ended to give way to the I 

I. — In our day a profound, a radical revolution has occurred in medicine. 

It would undoubtedly be necessary to go back to far distant tin. 
order to discover the first origin — the point of departure— of this mighty 
change, whose influence we still feel to this day. But the direction of 
this movement has been distinctly marked out, and its aim has been most 
brilliantly set forth, only toward the end of the eighteenth and the I 
ning of this century . 

It would be going quite too far if we were to say that an unfathomable 
abyss opened just at that period and separated the medicine i 
from that of modern times. No : traditional ties are not sundered : the 
labor of times gone by is not lost ; and we shall treasure up the immense 



1 Dechambre : Introduction to the Dictionnaire Encyclopediquo u^ I M6dt- 

cal« j, p. xix. 



THE DISEASES OF OLD AGE. 3 

heritage which our predecessors accumulated in the course of centuries. 
Still, it must be confessed that new horizons have opened to us, and that 
the views of modern science are from a standpoint which has risen as it 
has altered. 

The forerunners of this reformation were Vesalius, Harvey, Morgagni, 
and Bichat, the creator of general anatomy. Corvisart, Laennec, and 
Broussais co-operated to a very great extent in the movement ; and now 
come our immediate teachers, and it is with pleasure that I ask you to ob- 
serve that all these names are names of Frenchmen. 

It appears that the marvellous progress made by experimental physiol- 
ogy in these later times, under the influence of Mtiller, Claude Bernard, 
Longet, and Brown-Sequard, has finally brought over even the tardy and 
the timid, and settled the question. 

The essential characteristic of this revolution consists in the direct, the 
immediate — and we will say legitimate — intervention of anatomy and phys- 
iology in the domain of pathology. 

Before the period when this revolution occurred, medicine was almost 
wholly restricted to the study of symptoms ; after that time it became, in 
succession, anatomical, then physiological, and next acquired decided scien- 
tific tendencies. 

The fundamental principles accepted by modern medicine can, I think, 
be asdribed to two characteristic features. 

In the first place, symptoms which used to be considered in an abstract 
manner, and, to a certain extent, apart from our organism, are to-day inti- 
mately connected with it ; according to Bichat's precept, the seat" of the 
malady should be sought for. 

The inflexible logic of Broussais forced him to proclaim that he knew 
of no derangement of function without a corresponding lesion of an organ 
(we should rather say tissue to-day) ; symptoms, then, are in reality noth- 
ing but the cry from suffering organs. 

In the second place, it was possible for the ancients to consider disease 
as a thing independent of the organism — as a sort of parasite clinging to 
the economy ; while to-da} r — and again to Broussais we owe it for having 
succinctly asserted the principle — it is merely a disturbance of the inherent 
properties of our organs. It is here no question concerning the appear- 
ance of new laws, but only of the perversion or derangement of pre-existing 
ones. 

We recognize the enormous part which the sciences of anatomy and 
physiology are henceforth to play in the interpretation of morbid phenom- 
ena ; but is that saying that these' two branches are to absorb pathology 
and rule it with an absolute hand ? 

Gentlemen, a serious difficulty, demanding discussion, presents itself at 
this point, and I ask your permission to enlarge somewhat thereupon. 

It is absolutely certain that pathology can be greatly illumined by 
physiology, but it is just as certain that it cannot be deduced from physi- 
ology. 

Allow me in this connection to recall to your minds a profound thought 
which is found in Hippocrates : " Who could have foretold," says he, " from 
the structure of the brain, that wine could derange its functions ? " M. 
Littre, who quotes this passage, adds the question : " Who could have been 
taught, by his knowledge of the human body, that the emanations from 
marshes would cause intermittent fever ? " It is, as you see, a complex 
problem. Really, in addition to the physiological condition supposed to 
be known, it is likewise necessary to search for the manner, which is in- 



4 CLIXICAL LECTUEES OX 

fluenced by the action of the morbific cause. In other words, in order to 
know what will be the effects of any morbific agent upon a healthy organ- 
ism, it is indispensably necessary that experiment! shall have been made. 

Thus you see that pathology, hi the jnesence of anatomy and \ 
ology, has the right to preserve a certain degree of independence, and to 
possess a certain amount of autonomy. A pure and simple - 
pathological facts evidently furnishes us with data of th< 
tance, needing no rapport other than that they furnish o( 
those, so to speak, constitute ti 1 of medicine — a 

The intervention h< n of biolof IS without - usable, 

including, too, the physico-chemical ba . hich an lith 

biology ; and in default oi 

be made at random, us if w< I in the dark ;' still. U 

deeply pathologica] observation mb- 

ordinate one ; th< 
lines, and wishes to ooofi] 
consideration of them in their natural relationship. ih 

true character of empirical m< 
dignity of its etymological 

by that title the - ncinc wh< lte, 

and in a period when re not unit 

logical tin i 

\v | _ ;.:: 

ganization, and into the i 

mall have unveiled all I 
understood every modinc 

LOiny — that il 
reality is far. very far, from approaching this 

anatomy its. If, all are in process of B fo luti 
Hi DOB, 1 think t: 

that nave been m< 

'cinatical. :.d. win'.. 

avoid, as Borden aaya, a forced and unwilh- 
empiricism, 

With tl ■ ense ser- 

renden fchology 1 

physiology, ami to boldly assert that in it lies the ful 
I besides, out 

which ought to he accorded to pi 
they Lacked more exact and t v 

lema which they sometim 
t< rmined their profoundness. 

have striven to interpret pathological fa 
the physiology then in vogue. 

iinieal oba In our tini« s KD P**t 

con: 

! anatomical and physiological science.*' (Ch. Robin: J oaraai del' Anatomic, eta, 
. p, 8870 

- ad actioi 
bus Lh aaturaui u:orbi inde ueccss&rio sequentia.*' 



THE DISEASES OF OLD AGE. 

Just here allow me to repeat to you the very words of Dareniberg, who 
gives his opinion on this point with all the authority which a thorough 
knowledge of history imparts. He says : " Nothing is better than a good 
physiology, or at least a physiology which, grounded on experience, still 
carries within itself inexhaustible germs of perfection. Such a physiology 
reforms medicine and transforms therapeutics ; but, again, nothing is more 
disastrous, more opposed to the progress of pathology than an unsound 
physiology, than an " d priori " physiology, which daily finds in itself the 
best reasons for plunging deeper and deeper into obscurity, and restraining 
the flight of science. It was in vain that the most dehcate and difficult 
observations multiplied in the Hippocratic school at Alexandria ; ideas arc 
more stubborn than facts. Physiology resists so bravely, that it miscon- 
strues the discoveries of anatomy and the conquests of pathology, in order 
to bring them under its laws. Very different was it when beneath the 
hand of Galen the experimental method, already touched on at the Alex- 
andrian school, transformed the physiology of the nervous system ; then 
the whole aspect of medicine changed.'" ' 

Now, gentlemen, that " d priori " physiology alone is responsible for 
those too notorious systems which, at various revivals, hare excited such a 
baleful influence upon the development i — Naturalism. Stahlism — ' 

and all the forms of ancient and modern vitalism, not excepting that of 
Bichat, touch it on the one side ; and iatro-mechanism ' and iatro-chemis- 
try, 4 on the other. 

The firmer take away the principles of life from the organism, so that 
they may govern it as would a capricious ruler ; while the others daringly 
attempt to give a physical or chemical interpretation to lite, and this, too, 
at an epoch when the real relation of biology to the physical sciences 
not even surmised. Happily, such errors are impossible in our times 
Placed upon a solid basis, physiology can no longer be dangerous to medi- 
cine ; on the contrary, it has become its most solid support It encloses it 
on every side, if I may n pression, in a net-work with compact 

meshes, no longer permitting rash speculations to pass through it ; and 
even if, in our times, errors are yet committed in some instances, they 
only evince a faulty application of the method, and not an error in 
principles. 

AVise and well-balanced thinkers have, always energetically protested 
against usurpation by an unsound physiology; and from this standard we 
must look with admiration upon those physicians who were devoted, on 
principle, to the cultivation of pure observation, from among whom towers 
the mighty form of Hippocrates in the foremost rank. 

Gentlemen, what are the products of that medicine systematically 
isolated from all extraneous contact, and consequently reduced to its own 
forces, and founded upon pure observation? What is its character, how 
much may it claim, where does its province end ? Here are questions 
that certainly deserve to be examined. History offers in this respect a 
series of experiments made for us. prolonged over the several centuries, and 
whose results are to-day offered for our estimation of them. 



1 Ilt'sume dc THistoire de la Medecine, etc.: Union Medicale, 18G5. 

2 Stahlism: the "■ phlogiston theory." — L. H. 11. 

3 Iatro-mechanism : a svstem of treating diseases by the application of mechanical 
forces.— L. H. H 

4 Iatro-chemistry : a system where diseases were treated with chemical prepara- 
tions. — L. H. H. 



6 CLINICAL LECTURES OX 

LI. — But this leads us back into the vers* midst of antiquity, to the best 
days of Greece — to the time of Pericles. ' 

In this epoch anatomy was in a most rudimentary condition ; the nervous 
system had not as yet been distin. Erom the tendinous struct 

The brain was considered a gland. They thought that the 
filled with air, and the real distribution of the veno' ifi wholly 

unknown. 

Physiology was even below this level ; it was grounded only upon fan- 
tastical notions ; it had not i from tl t< .tive 
philosophy of that period, which, in ill 
knowledge of the universe, ign 

and e\( u thought this alii. 

error of Greek philosophy 

which had produced such dazzling 

applied to Objective reality, and tli 

most evident axioms were d< 

In the midai 
the Bohool of ( tea 1 spring up. I 
directed against the Cnidian 4 phyaiciai] 
the philoa >phy of tl i 

medicine should | 

h\ pothesis ; and in this way 1; 

miration of every 

It can be compared fa 

bj masters who had only 

have not vet learned to surpass, with all i 

Hippocr 

lines, without pretendi] 

He thus views it in its k r to as- 

m the modifications which it undergoes boa 
This Last standpoint leads up 

where the intluee 

that I nd out in bold relief. 

As the 3 -es successively through ti- 

the dry and the W< 

doctrine of medi< 
pherio conditions, a doctrine which still 

rations which it lias sum red. Wear- it. 

Climate, as it w« ; 
more marked since its inihu i. 
and free, if the Asiatic nd slaves 

mate in which th- >u see, is 

the geographical fatalism— a d 
tunes by Herder, and 

worked up with so mueh skill under the title oi tl.. 

ment " (Tneorie dea milieu 

who can question the infill 

1 In this pnssag-o 4 it will be eu; 
sxoellent explanatory inn ...o works >. . 

nlc do 1;\ Philosophy 
I in the .1" l>ocratc8. — L. II II 

'Onidoa, an island i L U. 11. 



THE DISEASES OF OLD AGE. 7 

and mind, find above all, upon diseases which may affect us ? Following* 
out this analogy, Hippocrates looked upon ages as the seasons of life, and 
consequently attributed special diseases to them. Without accepting this 
interpretation, modern science has still fully confirmed the truth of the 
fact, and we know that there are diseases which pertain to the different 
periods of life. 

That which attracts us at the onset and impresses us most strongly in 
the Hippocratic pathology, is the importance he accords the general con- 
dition, and the indifference he exhibits witli regard to the local state of 
affairs. This point of view will appear singularly exclusive unless we re- 
member the conditions under which Hippocrates made his observations. 
He concentrated his attention pre-eminently upon acute febrile diseases, and, 
as M. Littre lias remarked, without doubt more especially upon the remit- 
tent and pseud- )- continued fevers which are as prevalent in Greece to-day as 
they were in the time of Hippocrates. Now, it is a recognized fact that 
fever almost always involves the same state of the system, independent of 
the causes which produce it and the different forms it may assume. But 
that which, according to Hippoeral >f prime importance, consisted 

in discovering certain signs which enabled mptoms, and the ter- 

mination of the disease to be fo and which furnished indications for 

the exhibition of remediea 

It was to attain this end that ho attentively examined the features and 
the color of the face, the attitude of the patient, the he it of the body, the 
respiratory movements, the urine, sweat, and the various evacuations. Is 
it not with almost the same end in view that we try to rind out the state of 
the forces, the amount of arterial tension, and the oscillations of the i 
tral temperature, when the local condition it furnish useful indi- 

cations? 

And the theory of erii after en. luring the stern test of modern 

criticism, has still survived, though stripped of the intentional character 
ascribed to it by the ancients. 

You bleinen, from this rapid outline of the pathology of Hippo- 

crates, what results the method of observation may Lead to ; the facts gath- 
ered by it, and views it has proved, resist the action of time. They have 
reached us without having lost any of their striking truth. And we further 
state that, without transgressing its legitimate prerogative, this method may 
ueral views and furnish data of a superior order. 

If in reality there exist an observation especially analytical and limited 
to detailed facts, in which the moderns have noticeably excelled, then 

ition on a grand scale, more familiar perhaps among the an- 
cients — one which is not confined to the examination of isolated phenomena, 
but which views them, on the contrary, in their mutual relationships, in 
their order of succession : such, definitively, as nature offers to him who 
knows how to view things from a somewhat elevated standpoint. 

Thus we have come to recognize that every disease has its own evolu- 
tion, a special manner of development, a peculiar series of symptoms, 
which allow a description to be made of it after a common type in the 
midst of variable, accessory circumstances. 

Thence has issued the idea of unities or morbid species, a notion per- 
fectly correct since it corresponds to a fact of experience, but the significa- 
tion of which has been strangely altered when things have gone so far that 
diseases are regarded as concrete beings liko individuals, by the same 
right as an animal or a plant. 

W« know now that a disease sometimes runs rapidly through the sue- 



8 CLINICAL LECTURES OX 

cessive stages which are part of its natural history, to reach its termination ; 
and we know that sometimes, on the other hand, it requires a long space 
of time to pass through its various phases of development. Thus arises 
between acute and chronic affections a distinction which evidently answers 
to the results of clinical observation, but which ought not to be looked 
upon as a line of absolute demarcation, since the acute and chronic form 
of one and the same pathological condition often merge into each other by 
imperceptible transitions. 

We have further seen, by observations which have multiplied, that va- 
rious morbid states coexist or succeed one another in the same person or 
in the same family, following a definite order and after certain laws ; and 
hence it has been concluded, by a very simple process of reasoning, or 
rather by direct intuition, that those diseases were not isolated, and that 
they must unite in a common cause which served for their bond. In this 
way the grand conception of constitutional diseases and diatheses was pro- 
duced, and this idea originated in pure observation. Hypothesis does not 
commence until the moment when, in order to attribute existence to this 
unknown cause, the mind, following the bent of the day, has now ascribed 
an influence from the nervous system, and now a modification of the 
of the humors, or the presence in the blood of some morbific material. 

In the course of time, analytical has succeeded synthetical observation, 
which has not, moreover, been always neglected. And thus, as the world 
has grown older, science has been successively enriched by an immense 
number of general or partial facts, which positively constitute the only tra- 
ditional medicine that commands resi 

"We have now arrived at the limit of this rapid review. The examples 
I have given are sufficient for us to appreciate the resources of the method 
of observation applied to medicine, even when it voluntarily confines 
to the sphere of the external phenomena of disease, that is to say, the 
symptoms. 

But it is easy to recognize at the same time that a pathology thus de- 
prived of its natural support can amount to nothing, even in the most skil- 
ful hands, but a more or less elevated empiricism. It is that which un- 
doubtedly constitutes the common, the fundamental course of all scientific 
construction, and it has even been possible to establish upon such a 
a practical medicine which nothing hinders from arriving at a certain de- 
gree of perfection. 

But the work remains incomplete, and the human mind, urged forward 
by an irresistible force, is not able to stop by the way. 

The efforts it has made to finish its task have of necessity been futile 
so long as anatomy and physiology were not established. And tins should 
make us indulgent toward those systems which have anoc 
from antiquity to our days. But at last the time has come, reform 
complished, and we may now appreciate what fruit it has produced and 
foresee what it will bring forth in the future. 

m. — Clearing with a single bound a period of two thousand years, we are 
now to confront the results of pure observation with the work of the mod- 
ern mind, armed with all the means of investigation which it to-day 
sesses. And to render the contrast more striking, we shall pass over in 
silence the transition epochs so as not to be busied with anything except 
the scientific movement properly belonging to tins, our century. 

You have, gentlemen, no doubt heard mention several times of a 
pathological anatomy, as opposed commonly to the pathological anatomy 






THE DISEASES OF OLD AGE. 9 

of the ancients. It is proper that we should at the very onset distinguish 
what each expression signifies. 

I shall speak just here of an historical point to which I ought to direct 
your attention for a moment : it is quite recent history, for it is not so long 
since pathological anatomy asserted itself for the first time as a special 
branch of science. One of the first attempts at systematization which be- 
came law, dates from 1812. The statement of the doctrine — its code, as it 
were — is found recorded in one of the first articles of the great " Diction- 
naire des Sciences Medicales." 

This document, precious on so many accounts, bears the signature of 
two illustrious men — Bayle and Laennec. 

I wish to attempt, gentlemen, to characterize in a few words that first- 
named pathological anatomy which has for half a century held undisputed 
sway. , 

Its means of investigation are very simple : it takes the word anatomy 
in the rigorous exactitude of its etymological sense, and knows nothing 
besides save the scalpel. 

For it, the alterations occurring in organs can be determined only after 
changes have taken place in their relations, volume, consistency, density, 
color, and general aspect. 

It is impossible, as a general rule, to look for characteristics of modifi- 
cations in texture, since this is almost always ignored. 

What efforts must be made in order to establish the identity of an 
anatomical type with the aid of such data ? But the masters surpassed 
themselves, and produced in this manner more than one inimitable model. 
In spite of all things, every one understands how difficult it is to fix in the 
mind such fugitive traits as those, for example, taken from the aspect and 
the color. These have shades and contrasts which the most picturesque 
language finds it difficult to express. Thus the anatomo-pathologist has 
many times felt the need of becoming an artist, or of invoking the aid of 
the stranger's pencil. It is quite natural that art should intervene here, 
where the figurative side has such great importance. To its co-operation 
we owe more than one precious collection, and, above all else, the imper- 
ishable monument erected by Professor Cruveilhier, under the name of 
"Atlas d'Anatomie Pathologique du Corps Humain." 

From the commencement it was foreseen that a day would come when 
all the lesions that the eye could not perceive would be definitely described, 
classified, and catalogued. It was thought that then the work would be fin- 
ished, for it was not known from what side improvement could come. That 
is undoubtedly why the heads of the school did not dream that their science 
would play any but a very modest role in the whole sphere of pathological 
science. They even at all times endeavored to circumscribe it within nar- 
row limits, as if they wished, by this means, to preserve it from all the 
allurements which might have compromised it. 

In the first place they hasten to declare that their anatomy is applicable 
only to a limited number of diseases, since many of them do not possess 
lesions which are appreciable by its means of investigation. 

And further, even in the domain of organic diseases, where it would seem 
right for it to obtrude, its part is still not a very ambitious one. Indeed, 
the object is, above all, to enrich nosology with new lights, allowing discrim- 
ination between diseases the analogy of whose symptoms might have led 
to their confusing. The distinction being stated, the end was attained ; for 
pathological anatomy voluntarily limits itself — and on that point is fully 
resolved — to the viewing of lesions by themselves, independent of the symp- 



10 CLINICAL LECTURES ON 

toms which accompany them. It is not necessary to look for any explana- 
tion here concerning the proximate cause of disease, or th. 
its formation. 

Such, gentlemen, if I do not mistake them, are the most original fe: I 
of this pathological anatomy, thai 1ms sometimes been ironically c 
dead anatomy." I have not i Lieve that at least I have 

faithfully portrayed the tendenci 

r i'li< or imitators I resaed the 

limits which they imposed upon I rw the 

tracks of their brilliant incur sioi 
he closed to pathological anatomy. 

The method stood, DO : hut the me: 

was near when it wis to undi 

V.mi are acquainted, gentlemen, with t irhiefa tk§ 

anatomical school — for by this t i 1 1 Heine, 

with those limited and circn 

This is a point upon which i' > show 

that, even to this day, notwithstandh 
in various directioi 
all their author all their • 

naked eye, such as it has instituted, and like ti 

it made, will always constitut 
investigation must pass. 

m such c 
atomy can be called upon t i 

expand and develop it, 
Gentlemen, if I 

by the first pathol< 

sician /" think My. 

When circun 
evolution possible, . 
wholly renovated pli 
periiuent.il channel— tin 
then definitely fulfilled by I 
microscope. 

Then n:< n vin i' .08 an 

autopsy exhibits, with which 

it was the livin 

tic vl by the morbid condition which must be reconal 

physiological i 

pha-t s. often the List, oi :i 

back in order to p 

utline oi the i elves 

will confess that it would \v.v 
were it not for the co-operation of his 

Thus, as we have seen, th rinciple stops, as a matter 

of course, at the Bin 

in the study of lesions, it estima- 

tion by any systematic idea. 
alone is not simply I 

. a doctrine. 11. 
analysis m 
meni 



THE DISEASES OF OLD AGE. 11 

It is in these elements that the conditions of incomplete life may he 
truly said to reside ; an organ is hut an aggregate, a collective, a resultant ; 
and hence, hy the aid of the microscope and reagents, we must penetrate to 
the elements in order to get at the modifications which they undergo from 
the influence of morbific causes, and from these modifications to deduce the 
reason of the derangement produced in the whole organ. 

Thus, gentlemen, pathological histology, from which histo-chemistry is 
inseparable, has not its sole aim in a limitation of the number of non-mate- 
rial diseases, by showing that lesions may be present where the eye cannot 
perceive them ; in furnishing new means of diagnosis, new nosological 
characteristics ; neither is its part restricted to the unveiling of the hidden 
reason of anatoruo-pathological forms, recorded and classified by micros- 
copy, and to affix a more lasting and scientific characteristic to them, by 
ascribing each one to its corresponding modification in the texture of the 
organ ; its aims stretch still farther, for it also has for an object a kind of 
intimate pathological physiology, which, as it were, follows step by step the 
various phases of the morbid process in each elementary part, striving to 
avail itself of the least transition which binds the pathological to the nor- 
mal state. 

On this side you see that pathologico-histological anatomy touches on 
patho . or rather mingles with it, and at the same time also allies 

itself to physiology, which in this special direction takes the name of patho- 
logical physiology. 

Now, gentlemen, it is important to notice — for it is a characteristic fea- 
ture — that the end which pathological anatomy proposes to itself cannot bo 
readied without establishing an incessant a pproximation of the lesion that 
is studied even to the minutest details of its development, and the patho- 
logical circumstances minutely observed at tin- bedside. And in this man- 
ner, as a consequent obligation, as a logical necessity, pathological anatomy, 
in proportion as it penetrates more deeply into the intimacy of tissues, b - 
comes simultaneously more animated and living, tending toward a closer 
union with the clinical. 

However, gentlemen, in the face of a manifest functional derangement 
whose seat is indicated by physiology, histological analysis often remains 
even yet powerless to state what material vice corresponds to the disturb- 
ance of function. Is that saying that we must resign ourselves to the 
belief, contrary to all analogy, that a functional lesion, a derangement of 
organic properties, can exist without any corresponding material modifica- 
tion ? As for myself, were the question urged upon me, I should not hesi- 
tate to place myself by the side of l\eil, Broussais, Gorget, and many other 
eminent minds ; I would recollect that, even in the normal performance of 
the functions of life, the labor of the organs is not accomplished without a 
material change taking place — a correlative destruction and reparation. 
Every function tends to destroy the instruments by means of which it is 
performed. Muscle in a state of repose has an alkaline reaction ; it becomes 
acid when it is tired. 

An analogous modification has been observed in the nerves and the spi- 
nal marrow, and even the cerebral substance itself is, according to Heynsius 
and Punke, acid when the individual is awake, and alkaline during sleep. 
Such examples as these show us that in the anatomical elements the main- 
tenance of life is closely bound to the existence of an incessant molecular 
work which manifests itself by appreciable chemical phenomena. Is it not 
easy to conceive the existence of lesions of elements which, without altering 
their form, hinder that organic movement in the absence of which their 



12 CLINICAL LECTURES OX 

functions cannot be performed? "Without altering their form, carbonic 
oxide robs the red blood-corpuscles of their power of absorbing o 
Henceforth they roll along the torrent of the circulation, like so much inert 
dust ; and were it not for the change in color winch they present, nothing 
external would betray the profound change they have undergone I 
an analogous alteration in the blood-globules be at lessl 
tain grave conditions of the organism, when intense . with- 

out there being pulmonary i 

In those patients who rapidly succumb in the course of acute art; 
rheumatism, the blood and t rdium and the 

synovial sacs often have an acid | 
who are struck by lightning, anatomy i 

larerio rigidit itinoea 

scarcely a moment, and ilmoel immediately rri\ 

The same thing happens with over-driven ania 
mena occur, as Brown-Sequard 1 
have been i 

Is it not almost certain that all 

after death, c o rresp o nd I which aln luring 

life, but which hitn< I inaooi - 

tigation ? But I shall not insist npon this point ; I 
conducted you to a territory which is still almost urn 

promises abundant harvests in the fir 

IV. Qentlem 
actually to exist betwa d p 

The speculative i 

sidered here, but rati, 
us by the cessora ol 

and Mageiidic 

While fully r 

it exhibit* d in th 

belong to them, the new ph still abfl 

1 supernatural intlueiice V 

dictates, freeing itself from all 1 

brought over to proper; 

this moment one must : 'U be- 

these two orders of t 

It purposes to bring all I 
io workings of cert iratases, 

property dn well-defined tl 

It does not b si to find out the cs- 
rience has proved that the human m 
mate causes, or the conditions of p] 

It r. - that, in this the limits of our know" 

same in biology as in p] 
a certain point, nat , 
no longer gives an answer. 

ther, it mak< - 
lighten and furnish a solid 

It brings t I it. in reality. 

method, that admirable rhich in it 

so many mysteries. 



THE DISEASES OF OLD AGE. 13 

Thus, M. Claude Bernard, a great teacher in physiology, expresses him- 
self in various places of his remarkable work, with which you are all ac- 
quainted, and where, in a profound manner, he discusses the question with 
which we are here occupied. 1 

I shall limit myself to bring forth the express condition which he also 
imposes upon all legitimate intervention of physiology in the domain of 
medicine. First, pathological interpretation ; such, says Bernard, is the 
imprescriptible rule ; to first state the morbid phenomena, and then to en- 
deavor to explain them from the standpoint of physiology, when this is 
possible in the actual condition of science. 

The opposite procedure, which consists in starting from anatomy and 
physiology, in order to deduce the conditions of the disease, is full of peril 
and bristling with danger. Let us not be seduced by the elegant view, the 
ingenious ideas which it can suggest, for experience proves that too often 
it has led to an imaginary pathology corresponding in nowise to the reality 
of things. 

It appears useless for me, gentlemen, to dwell longer upon the innum- 
erable services already rendered medicine by the intervention of the data 
of modern physiology."' 

I wish, h«>\vc\er, to dwell for a moment upon what it is agreed to call 
experimental pathology. 

The mutilations to which the physiologist subjects an animal, in order 
to penetrate the mechanisms of normal actions, are almost always attended 
with various morbid disturbances which may already become a subject for 

thought to the physician. But experimentation may apply itself still more 

directly to the problems which pathology oilers to it. We have really suc- 
led in creating various morbid conditions in animals, either in causing 
them to sailer certain mutilations, or in submitting them to the action of 
poisons, viruses, venoms, putrid materials, etc. 

The idea of producing, in this manner, artificial diseases, is far from be- 
ing a new one, and we must go back to Lower, Baglivi, Van Swieten, and 
Autenrieth, in order to find the first traces of it. But, above all, it is in theso 
last years, and from the impulse given to it by Magendie, that experimental 
pathology lias really been constituted and assumed all its scope. The 
works of Claude Bernard, Longet, Brown-Sequard, Yirchow, Traube, Vul- 
pian. and many others, are ready to testify what can be attained by this 
method. Nevertheless, the brilliant results it has already furnished in its 
short career should not allow us to forget that certain limits seem to be 
imposed upon it. Experimentation succeeds in producing a temporary 
glycosuria by the aid of a traumatic lesion. It reproduces marvellously 
well the various symptoms of thrombosis and embolism. It accelerates or 
stops at will the movements of the heart. It induces at its pleasure all the 
symptoms of uraemia. Thanks to certain lesions of the nervous system, it 
originates pleurisy, pneumonia, and acute pericarditis, more or less com- 
parable with those observed in man. Recently it succeeded in developing 
in an animal the phenomena of traumatic fever, by injecting into its blood 
the liquid of another animal from the surface of a recent wound ; and thus 
was confirmed an idea promulgated a long time ago by a French surgeon. 

1 Introduction a 1' Etude de la Medecine Experimental. Paris, 18G5. Especially 
consult pp. 117, 119, 125, 127, 140, 330, 343, 347, 348, 358, and 369. 

1 Consult, upon this subject, the remarkable discourse delivered by my friend, Dr. 
Brown-S quard, before the College of Physicians of Ireland, February 3, 1805 : On 
the Importance of the Application of Physiology to the Practice of Medicine and Sur- 
gery. In the Dublin Quarterly Review of Med. Sci., May, 1805. 



14 CLINICAL LECTURES 

But those diseases which have a slow process of evolution can he said to 
escape it most often. 

Constitutional diseases and diatheses, in particular, seem to 
cessible to it ; ' and how can it be otherwise if the conditions of d 
inent of these diseases are those with which the physician 1 
unacquainted? Let us D 
existing in some respects, betf 
neons and certain slow intoxicati 
alcoholismus, which h 
tion of the csorresponding i 

f which my i 
produced in the 

lity. , , _ . 

• it may I 
certain d in their i 

symptoms thereof and 
always in the regular i 

late the stm! 

predisposition, and also enligl 
morbid conditions. Pinal 
sons, wl 
of a truly rational therapeul 

titlemen, itwould 1 
by combining clinical data with 
pathological histology, and pi 
arrive al a perfectly ratioi 
morbid conditio] 

ob» 

elusions which must now h 

'—I think 1 
the neo 

that method which I 
should : 
counterpoise 

' d But th< 
to W legitimately ii 

bed by the intervention ol 
l and ap] 
originatea truly rational d 

Such ia towards which 

advance along this path with pro 
premature generalization; that w. 
;, rilu l i • of renovation in which 

ill ask, what is th 

these grand notional H 
wsomuchadohadafikvorableinfl 
more aick cured to-day than in by- 

This gentlemen, is a no-v indiscrt < t qu ^ Ll « 

hut too easily turned 



THE DISEASES OF OLD AGE. 15 

with answering, in the words of an honored teacher, that art without 
science very soon degenerates into routine. 1 

Commonplace scepticism, which is so readily opposed to all progress of 
the human mind, is a convenient pillow for lazy heads ; but in this epoch 
there is not time to go to sleep. 



To place in its true light the favorable influence which, in another way, 
scientific tendencies might exert upon the advancement of medicine, it is 
sufficient for me to recall to your minds the remarkable transformation 
which this science has undergone during .the course of the lust twenty 
years in a neighboring country of ours — in Germany. Let us for a moment 
cross over to the other side of the frontier, and in thought go back to about 
the year 1830. At that time Schelling and his daring "Philosophy of 
Nature" ruled as absolute lords over the German mind. Poetical notions 
and transcendental conceptions were then the fashion; and a physician even 
permit ted himself, in a treatise on mucous fevers, to seriously compare a 
blood-globule with the terrestrial sphere because both were round, flat- 
tened at the poles, and both poasesai -d a central nucleus surrounded by an 
atmosphere. 1 

During that time medicine wafl reduced to a deplorable condition, al- 
though the Germane | I translations of the principal works relating 
to pathology, which hadjusi been published in France or England ; still 

the ] implished by I it-named countries was for the < 

mans as though it had never happened, for no one understood the impor- 
tance of it. Physical diagnosis had never been formulated, either in the 
hospitals or in private practice. 

In more than one German university the Btethosoope was almost un- 
known ; when they accidentally ran a CT O Ofl one of these instruments, they 
examined it with a sort of infantile curiosity ; or, again, they greeted with 

istic jests those few eccentric ones who by means of this bit of v. 
pretended to hear unheard-of things. \\< sides, most of the die t the 

chest and the heart, and chronic affections of the skin, were an almost un- 
explored region. 

Even when they began to take notice of the French, it was only to turn 
to ridicule, and this time with the appearance of justice, that strange mania 
which impelled them to consider all diseases as inflammations. ' 

Things remained in this state until about the year 1840. Then the 
work of regeneration commenced, chiefly through the influence of Schoen- 
lein, by the importation of French methods, and their intervention in the 
domain of the clinic. Then it became the turn of pathological anatomy, 
brilliantly represented at Vienna by Pokitansky. But Midler had already 
appeared with his physiology, and soon he created pathological histology, 
which was to remain tor a long period an almost exclusively German science. 

Gentlemen, you know the rest. Then the German universities pre- 
sented the spectacle, new to them, of an almost unheard-of feverish activity ; 
and you are not ignorant of the fact that that feverish labor, which even now 
does not show any signs of diminution, has already produced more than 
one fundamental work. 

1 " Practice without incessant scientific renovation would very soon become, be as- 
sured of it, a belated routine, and one as if stereotyped." Behier : Lecon d'Ouverture 
du Cours de Clinique Mc-dicale, p. 19. Paris, 1867. 

- H. Horn : Darstellung des SchleimfK'bors. 2 Auflage. 

3 C. A. Wunderlicb: Gcschichte der Medicin, p. 332. Stuttgart, 1859. 



16 OLIHICAl LECTURES OH 

During more than ten years tL. intellectual movement 

almost unnoticed \>y the French. From time to time some far-ee< 
server endeavored to attract pabHc attention to it, but he I 

r.il indiflfi ad while all < - in activir;. 

1 with oti 
we comprehend that a grand 
that it must be reckoned ami 
d'outn i 

and wbi 
inclined, perl 

with bug think tli il 

them alone. We should, | 
triumph. 

found thi which hi 

With the j)clitic:il | 

abuse tl • 

a strict patriot i 

should f 
such, to do r .•' \\ 
ilar let m 

"Reason," says < 

le world 
Individuals I 

- 
..o. translated bj Dr. JaccouJ. a 53. 1883. 



THE DISEASES OF OLD AGE. 17 



LECTURE I. 

GENERAL CHARACTERISTICS OF SENILE PATHOLOGY. 

Summary — Object of these Lectures — Organization of the SalpetriiTC Hospital from a 
Medical Point of View — Chronic Affections; Diseases of Old Age — History of 
Senile Pathology — Physiology of Old Age — Anatomical Chauges in the Organs 
and Tiseues — A complete RemtmS under the Term Atrophy — Exceptions in the Case 
of the Heart and Kidneys — The Various Derangements Resulting from these 
Modifications in Structure — Certain Functions Diminished in Old Age, and Others 
Preserved — Pathological Immunities of Old Age ; the Peculiar Impress it gives to 
the Greater Number of Disea 

Gentlemen : — The lectures which VOU arc going to attend arc meant to 
bring before you in review i: interesting clinical facts which the 

Salpetriere Hospital can present to your observation. Those among you, 
gentlemen, who until now have frequented only the ordinary hospitals, 
may expect to see pathological I with quite a strongly 

marked local color 

You arc, no doubt, acquainted with the internal organization of this 
itablishment. 1 
sing out of consideration the employe^ and also the number of 
lunatics, idiots, and epileptics, who form a Separate and distinct class, th< 

mainder of the population of this asylum consists of about twenty-five hun- 
dred females, who, with some few exceptions, belong to tho least-favored 
portion of society. 

From the standpoint of a medical clinic, which alone should engage 
our attention, they form two very distinct catego: 

The first is composed of women who are, in general, over seventy years 
of age — for the administrative statutes have so decided it — but who, in all 
respects, enjoy an habitual good health, although misery or desertion has 
put them under the protection of public aid. Mere, gentlemen, is where 
we shall find the materials which will serve us in making a clinical history 
of the affections of the senile period of life. 

The second category comprises women of every age — smitten, for the 
most part, with chronic, and, by repute, incurable diseases, which have re- 
duced them to a condition of permanent infirmity. 

In this respect we here possess advantages which those in the ordinary 
hospitals are, for the most part, deprived of ; and we are also placed in the 
most favorable position for studying with benefit those diseases whose evo- 
lution is a slow one. 

Indeed, the numerous population of these wards .allows us to observe, 



1 Those of our readers who desire more ample details upon the interior arrangements 
of the Salpotiiere, as well as the history of the institution, can consult with benefit 
the interesting chapter reserved for The Hospital for the Aged (women), by M. Hus- 
ton, late Director-General of Public Assistance, in his Etude sur les HJpitaux. Paris. 
1883. 

o 



18 CLINICAL LECTURES OX 

under the most diverse aspects, the principal types of one and the same 
morbid species ; but, what is still of greater importance we are here per- 
mitted to follow the patients through a long period of their existence, in- 
stead of being present only at a single episode of their history Thus we 
see developed to its utmost limits the pathological process whose initial 
phase is usually the only one known ; in fact, we are called upon to state 
the organic lesions which characterize the disease when it has been termi- 
nated by death. _. . , ^ 

In other cases -unfortunately but too rare— we see cures effected some- 
times spontaneously, sometimes induced by the hap; i ution of the 
art But that which we learn to recognize here bettor than anvwh 
else, is the value I ached to those means which alleviate when / 
impossible for us to C Q . 

To-day I purpose calling your attention more especially tot; 
eral characteristics of I « hich sin .pon the last period of life. 

I— The importance of ■ special study oi the diseases of d root 

be contested atlhis day. We haw 
pathology of childhood oonni 

kind and il H is indifl that it should b 

point of view, then ak «'"*- 

not be surmount nce 

with its peculiar characi . , 

\ml yet gentlemen, ti 

lectedforalongtime.anci «d mob 

°^hrTat an' epoch v*r, w> in Y. 

that the pathology of old 

allowed the cxpiv^.n, in all 
scarcclvcitca\vorkinwhichthcsh,h-, 

particuL physiognomy of the 

rcatisc of Vlinvr, published in L724 
lastly that of Vi>h,r. which da 
WOT** of the past ccnturv which touch, in a 
p.nodofhfcSiavcahtcraryoraphil, 

, ingenious parap] 

r^reaeVved for K fff.^ SUttlJ 

ever atthe epoch when h 
Sxiere Efosptod was already organ 
which had formerly been part of the institution . 
the infirmary had been found* 
the W>td-Dieu at the risk of dying on the v. 

But IW could not think of rotrainn 
of science. Much more ambitious 
lus idea was to embrace pathology hi 
philosophical nosology by applyin. 
cordnm to the rather emphatic hu f the eight 

the ditVerences which separate senile from ordinary j 
rluvlv I mud described in his writings, although he pass, eater 

portion of his medical life in hoapil ** the a 

,er : IMirina Qenoauioa. iW.iv ■*• «■*>• l ** 

iel : Trait* de Mod. Ctinique, Inteodootiea, p. am rm 



THE DISEASES OF OLD AGE. 19 

To Landre-Beauvais, one of the scholars and successors to Pinel at the 
Salpetriere, we owe the first special description which had ever been given 
of a disease met with at every step in the wards of this hospital, although 
it is not exclusively a disease of old age. 1 

I speak of nodular rheumatism (rheumatisme noueux), called also arthritis 
pauper um, which is a very frequent disease among the indigent classes. 
Landre-Beauvais designates it by the name of primitive asthenic gout, while 
at the same time he recognizes that it differs from true gout. Here, gen- 
tlemen, is a formidable affection on account of the infirmities which it in- 
volves ; in every respect it deserves to be put in the first rank of those 
chronic diseases which prevail in this hospital, and to which, later, we are 
to devote our attention. 

The clinical lectures delivered at the Salpetriere by Iiostan, about the 
year 1830, had immense publicity at that time. Several questions relating 
to senile pathology underwent a profound study at the hands of that emi- 
nent professor. 2 

Two of his works, above all, remain justly celebrated. The first has for 
its object to prove that the asthma of the aged is not a nervous disease, but 
one of the symptoms of an organic lesion ; and to day we know that, 
although this proposition when taken in its general sense is too absolute, 
yet it is not the less true in the great majority of cases. The second is a 
remarkable study upon cerebral softening, which has completely trans- 
formed all our notions upon the subject. It is known, according toRostan, 
thai this alteration, which is so frequent at an advanced period of life, far 
from being the result of inflammatory action, is a senile destruction pre- 
senting the most striking analogy to the gangrene occurring in old age; 
and the researches of observers, aided by all the modern means of investi- 
gation, have abundantly confirmed this idea. 

The immense amount of material laboriously gathered by Professor 
( ruveilhier, during his stay in the Salpetriere, has contributed hi a great 
measure to the construction of an imperishable monument — I mean the 
" Atlas of Pathological Anatomy." Innumerable observations, which have 
shed a new light not only upon the pathology of old age, but also 
upon the history of many a chronic affection, are found accumulated in this 
vast work. 

On account of a more or less direct impulse from the great teachers 
whom we have just mentioned, several important monographs relating to the 
diseases of old age have been jmblished by observers who drew the ma- 
terials for their works from this hospital. I shall only mention the remark- 
able memoir of Hourmann and Dechambre upon pneumonia in the aged, ! 
and the treatise on cerebral softening, by Durand-Fardel. 

But, to constitute in reality a senile pathology, these scattered frag- 
ments must be brought together in a systematic manner. And such was 
the end which Prus sought to attain in his "Researches upon the Diseases 
of Old Age/' presented to the Academy of Medicine in 1840. But, in this 
direction, the French writer had been preceded by Canstatt, in Germany ; 
to the latter author we owe the first dogmatic treatise that has appeared 
upon the diseases of old age. 4 



1 Landre-Beauvais : These de Doctorat, an VIII. 

2 Memoire snr cette question : L'Asthme des vieillards, est-il une affection nerveuse 
1817. Recherches sur un Maladie encore peu connue, qui a requle nom de Ramollis- 
sement du Cerveau. By L. Rosian, Physician to the Salpetriere. 1820. 

3 Archives de Medecine. 1835-3G. 

4 Die Krankheiten des hoheren Alters, etc. .Erlangen, 1839. 



20 CLINICAL LECTURES OX 

Unfortunateby, this work, which bears the date of 1839, was comp 
under the influence of Schelling'e doctrine, which so long reigned ac. 
the Rhine, and which bears the ambitious title of the "Philosophy 
Nature." In it imagination occupies an enormous amount of room at the 
expense of positive and impartial observation. Still, we do find in the 
work of Canstatt ingenious and often true ideas, which insure him an 
honorable place in science. 

An entirely different method inspired the studies of Beau ' and of Gil- 
lette 5 ' upon the d of old age, as well as Durand-Fardel's M Tl 
Clinique," published in L864 In addition to these synthetical works, we 
might cite numerous monographs relating il points on senile 
thology ; but we do not pretend to name all, and, 1 ill have 
more than oik tocaaiou to allude to I rks in the course of our 
lectures. 

We shall finish this brief historical sketch by mentioning three inter- 
esting foreign works, recently published, from whicl ntly 
borrow. Thenrsi 'luminous •■("iini uses 
of Old Age,*' from the pen of I >r. Geist, PI th< Hosj ital of the 
Saint Esprit, in Nuremberg, The second is a "Collection of I Ob- 
servations," written by Dr, M tfa ol ipital for I i. in 
Frankfort The third is the work of I published in London in 
lM'.i. 

II. — There is a common cl tic which is found in all th< 

I have just named to you : this is a mai 

possible, the particular points which are distinctive of the diseases i 
lty to the anatomical or physiolo. I which occur in 

inism solely on account PI not womhr at this, if 1 

that nearly all these writ in 

aide, \^ the orgai the 

modifications under di 

possible light upon the history i^{ diseas. 

We shall have to noti other t' inges 

which old age induces in the organism sometum a point t 

the physiological and the path bj an inn 

oephble transition, and to he no longer sharply distinguish 

I shall, then, undertake to .natomy and f 

iology of the senile condition, but not without 

always to look upon them fro; I shall limit 

to the indication of the most general c 
upon details, it will be only for the purpose of dedue:. 
to practical medicine from them. 

Certain general modifications at once arrest our attention. You an 
familiar with the external appearance of an old man — that 
skin, those thin and gray Lock mouth, the st rm 

which is bent upon itself— all ti .. 



' r.tmlcs QiniqBM rax 1m ™*1 de Medecine de Beau. 

Art. ViftlUeBM, in the Supphment M Pietionnaire dca Did ■ Mede- 

eiiuv Paris. 1861, 

Goist: Klinik der Greisenkrankhon n. TlllUgaa, 1N>0. Mottenheimer 

•ir l.ohiv d«X Groisonkrankhc. 



THE DISEASES OF OLD AGE. 2L 

of the individual, for, at the same time the stature diminishes, the weight 
of the body becomes less, as Quctelet has proved. 1 

A more or less pronounced emaciation usually corresponds to these 
various phenomena. However, you may meet with a different state of 
being — that is, as they used to say, the habitus coi'poris laxus, characterized 
by an accumulation of fat beneath the integument and deep within the 
splanchnic cavities. But this is generally a transitory condition, and it is 
not long before it gives way to the habitus corporis strict us, which is the 
-almost exclusively prevailing state at the period of decrepitude. 

That emaciation spoken of is the consequence of a morbid process 
which exerts its action, not only upon the muscles of organic life and upon 
the various portions of the skeleton, but also upon the greater number of 
the splanchnic organs ; the brain, the spinal cord, the nerve-trunks, the 
lungs, the liver — in fact, all the blood-making organs — participate in this 
retrograde movement ; the sjDleen and the lymphatic ganglia undergo a re- 
markable diminution in weight and in volume, which diminution advances 
with age. 

But, by a very remarkable kind of contradiction, the physiological rea- 
son for which does not yet seem to us to be sufficiently established, the 
heart and the kidneys arc exceptions to this law,*' and preserve the dimen- 
sions found in middle life. Indeed, in many old people the heart is seen 
to undergo a genuine hypertrophy ; 3 this, it seems to me, is a pathological 
condition dependent upon that arterial degeneration which is called senile. 
On its side the net-work of capillary blood-vessels grows poorer and poorer, 
not only in the principal viscera, but also in the deep parts of the skin and 
the mucous membranes. The latter at the same time lose a portion of 
their villous and glandular elements in the intestinal canal.* 

Of what does this atrophic action, which exerts its forces upon the col- 
lective organs and tissues, consist ? First, and in the highest degree, it is a 
simple process of atrophy ; the cellular elements of the parenchyma, the 
muscular, and perhaps also the nervous elements, progressively dimmish in 
volume, but without presenting any essential modification of structure ; 
this is pre-eminently noticeable, according to Otto Weber,* in the muscles 
of the aged where the elements are pale, of small dimensions, and all very 
nearly equal in volume, contnuy to what is the case in adult life. Connec- 
tive-tissue, however, does not participate to the same degree in this work 
of slow destruction ; it is even seen to predominate over the specific ele- 
ments in the viscera ; and this has been well established by Dr. Bastien in 
the case of the liver and the majority of abdominal organs. 

But, in a more advanced stage, atrophy is accompanied by a degenera- 
tive action ; that is, the elements undergo modifications in their chemical 
constitution, and become the seat of pigmentary or fatty degeneration 
and calcareous incrustations. This, for example, is what occurs in the cells 



1 According to Quctelet (Book II. , chap. ii. ), man attains his maximum weight at about 
the fortieth year ; he commences to lose weight at about the sixtieth, and at eighty he 
has lost at least six kilogrammes (thirteen and one- fourth pounds). In women, the 
maximum weight is attained at fifty. — Sur l'Homme et le Developpement de ses Fa- 
culties. By A. Quetelet, Perpetual Secretary to the Royal Academy of Brussels. Paris, 
1835. 

2 Rayer : Maladies des Reins. Vol. i., p. 5. 

3 It is hardly necessary to recall here the justly celebrated work of Bizot, inserted 
in the first volume of the Memoires de la Societe Medicale d'Observation de Paris. 

4 Berres, after Geist, loc. cit. N. Guillot : Recherches sur la Membrane Muqueuse 
•du Canal Intestinal. Jour. l'Expcr. Vol. i., p. 101. 1837-38. 

1 Handbuch der allgemeinen und sp. Chirurgie. Vol. i., p. 309. Erlangen, 1865. 



22 CLINICAL LECTURES ON 

of the brain, as we are informed by Professor Vulpian, the perfect exacti- 
tude of whose statement I have frequently been able to substantiate. 1 
According to Virchow, at the same time that the neuroglia tends to pre- 
dominate over the nervous elements in the encephalon, it habitually becomes 
infiltrated by a more or less considerable number of amyloid granulations ; ■ 
the brain-tissue then undergoes a chemical alteration, according to the re- 
searches of Bibra, which were confirmed by those of Schlossberger. 3 The 
fatty materials which enter into its constitution suffer a notable diminution, 
while, on the contrary, the proportion of water and phosphorus is in- 
creased. 

And yet, according to Vulpian, 4 fatty granulations are deposited in the 
primitive muscular fasciculi of animal life, solely because of the progress of 
age ; and this alteration may attain such a point in the lower limbs, where it 
especially shows itself, that a more or less complete paraplegia is the result. 
The muscular fibres of organic life do not escape fatty degeneration, and 
you will frequently have the opportunity to prove that the muscular wall 
of the heart is almost always the seat of it in women who die at an ad- 
vanced age. To this alteration in the cardiac tissue can be ascribed the 
phenomenon of asystolisni which is so often observed in old people, even 
when they seem to be in the best of health. 

Indeed, fatty granulations often fill the walls of the cerebral arterioles 
as Paget 6 has shown, ami Professor Robin also. 6 And it has been shown by 
Vulpian that this senile change is not peculiar to man, but that it is equally 
encountered in old mammals, in the dog especially. 

No one of you, gentlemen, will fail to observe that when these altera- 
tions shall have attained quite a pronounced degree, they will go beyond 
the limits of the physiological state, since they have the power to produce, 
of themselves, functional derangements which at times are extremely grate. 
This becomes especially clear concerning that change in the arteries called 
atheroma, and the calcification which is so frequent an accompaniment 
of it, 

From a standpoint of histological development, atheroma of the arteries 
tends to separate itself widely from the usual forms of senile atrophy. The 
latter seems to be the result of a purely passive process ; the former, on the 
other hand, seems, in the first phase of its evolution, to consist in a more 
or less active proliferation of the elements which are the normal constitu- 
ents of the internal coat of the artery. At a given time these newly formed 
elements suffer a fatty degeneration ; but this is a consecutive phenomenon. 
The granulations which have thus been formed accumulate in the deep 
portions of the internal lining membrane, and it is in these deeper portions 
where the process first appears and is most strikingly marked : the most 
superficial layer becomes distended with them, though it still resi-' 
quite a long time. In this way are formed those accumulations rich in 
fat and cholesterin crystals, which have been designated by the name of 
atheromatous abscesses. They are sometimes seen to open into the cavity 
of the artery avIiosc walls they occupy ; and their contents, mingled with 
the blood, may be swept into the general circulatory current, reach ves- 

1 Lecona de Fhysiolosrie Generate et Comparee du. Systenie Xerveux. p. 965. Faris, 
1866. 

* J Handbuch der sp. Pathologie. Vol. i. , p. 046. 

3 Consult Geist, op. cit., p. 158. 

4 Loc. cit. 

5 On Fatty Degeneration, etc.: London Med. Gaz. I860. 

6 Memoires de la Societe de Biolosrie. Vol. i.. p. o'A. I8t 



THE DISEASES OF OLD AGE. 23 

sels of a small calibre, and then cause those frequently formidable symp- 
toms of capillary embolism. In a less advanced stage the action of the 
atheromatous tumor is limited to narrowing, and later on to complete 
obliteration of the artery which is the seat of the degeneration. Then are 
produced in various portions of the organism those changes resulting from 
faulty nutrition, which constitute one of the most original chapters in the 
pathology of old age. In fact, we see that the majority of the cases of cere- 
bral softening and capillary apoplexy of the encephalon, occurring at an 
advanced age, result from atheromatous obliteration of the arteries :* it is 
the same with visceral infarctions, with that gangrene of the extremities 
called senile, and with many other changes as well. 

But here we are encroaching upon the domain of pathology, a thing 
we wish to avoid for the present. I shall now indicate in a few words 
those physiological modifications which correspond to the textural changes, 
the summary view of which has just been presented you. If it is true, in a 
general way, that with the progress of age all the functions are seen to be- 
come simultaneously enfeebled, yet it must not be supposed that this propo- 
sition is always infallible ; and it is only the analytical study of facts that 
can afford us any reliable information concerning the true state of affairs. 

The generative mechanism and the muscular force in the aged undergo 
so evident an enfeeblement that it is not necessary to insist upon this 
point. 2 And with regard to the functions of the nervous system of organic 
life, it is enough to recall the well-known lines of Lucretius. 

Prseterera gigni pariter cum corpore, et una 
Crescere sentimus, pariterque seuescere mentem. 

— u De Nat. Rerum," ii., 446. 

The functions of the respiratory apparatus, as a whole, are equally weak- 
ened, and we find the expression of it in a diminution in the quantity of 
carbonic acid exhaled, in an augmentation of the number of inspirations, 
and in the reduction of the vital capacity of the lungs ; this last result, ac- 
cording to the spirometrical researches of Wintrich, Schnepf, and Geist, 
begins to manifest itself about the thirty-fifth year of life, and reaches its 
maximum between the sixty-fifth and the seventy-fifth. 3 

Most of the secretions are diminished, the sweat and the urine in par- 
ticular ; and it is almost beyond question that the senile dyspepsia, upon 
which our renowned naturalist, Daubenton, has insisted in his great but lit- 
tle-known work, depends in great measure upon a sensible diminution of 
the gastro-intestinal secretions. 4 

But what are we to think of the functional weakening of the arterial 
system, when, according to Dr. Marey, & the heart of the aged is more pow- 
erful than ever, and the arteries present energetic pulsations ? It seems 
proved that, in all cases, the pulse augments its frequency in the senile 
period of life. 6 

1 It is to be clearly understood that we do not speak of intra-encephalic hemor- 
rhages, which have also been rather gratuitously attributed to an atheromatous degen- 
eration of the cerebral arteries. Later there will be an opportunity for further ex- 
planation on this point. 

2 Consult Empis : Etudes sur FAffaiblissement Musculaire Progressif chez les Vieil- 
lards. Arch, de Medecine. 1862. 

3 Geist: op. cit., p. 102. 

4 Memoire sur les Indigestions, qui commencent a etre plus frequentes chez la 
plupart des Hommes a l'Age de 40 a 45 ans. Paris, 1785. 
5 Etudes sur la circulation, p. 415. 
"' Leurefc et Mitivie : Sur la Frequence du Pouls chez les Alienes. Paris, 1832. 



24 CLINICAL LECTUEES ON 

We are but slightly acquainted with the degree of intensity which nu- 
trition manifests in the aged ; but the use of the thermometer has given 
us much more precise ideas with regard to calorification. Before having 
applied this instrument in researches upon this subject, it was believed 
that the temperature in old age was lower than in adult life ; but to-day we 
know that the heat of the central parts remains about the same in all peri- 
ods of life. It has even been supposed that the general temperature rises 
toward the end of life. 1 My own researches tend to prove that the only 
real difference which exists between aged persons and adults in this re- 
gard, is that in the former the axillary is much lower than the rectal tem- 
perature, while in the latter there is hardly any perceptible difference be- 
tween the two. 

Here is a woman, one hundred and three years old, and who is in excel- 
lent health ; the axillary temperature is 37.4 ( I 'ahr. ); while in the 
rectum the temperature is 38° C. (100. -4^ Fain*.), which is the maximum 
normal temperature in the adult. 

Thus, gentlemen, if old age enfeebles the greater number of our func- 
tions, it is far from paralyzing all of them ; and rigorous observation shows 
us that, in certain respects, the organs of the aged perform their tasks with 
quite as much energy as those of adults. 

m. — Gentlemen, the preceding sketch tells as that the progress of age 
establishes a wide difference in pathological phenomena, by virtue of its 
physiological modifications. 

We shall then study this question from three different standpoints : 

First. — There do exist special diseases of old age which, in part at 
arise from the general modifications which the economy has undergone. 
As examples I shall mention senile marasmus, senile osteomalakia. senile 
atrophy of the brain, certain alterations of the blood, 3 senile asystolisni, 
and lastly, arterial atheroma, whose study constitutes one of the most in- 
teresting phases of medicine in old age. 

>/ul. — Among the diseases which can exist at other periods of life, 
there are yet several which, during the period of senility, present special 
characteristics ; such, for example, is lobar (croupous) pneumonia. tL 
rible enemy of the aged, and one of the principal causes of mortality in 
this hospital. We shall later on recur to this part of the question. 

Third. — Old age seems to create, in certain regards, pathological im- 
munities. The eruptive fevers, typhoid fever, and phthisis, are quite uncom- 
mon at this period ; still these immunities must not have their importance 
exaggerated, for they are Car from being absolute, as Bayer has proved in 
the case of typhoid fever, Murchison in that of typhus, and other authors 
in cases of other diseases/ And who, besides, does not know that Louis 
XV. died of small-pox at the age of sixty-five ? 



^on Barensprung, in Canstatt's Jahresbericht. 1831; and Geist : op. cit. . p. 

- The frequency of intravascular coagulations in the aged seeraa to prove that there 
exists in them a tendency to inopexia. and purpuni miflfi conies under this rule ; for 
it is probable that this latter affection arises — at least it does so very often— from the 
spontaneous rupture of the capillary vessels. (Consult Wagner : Manual of Gen Path.. 
p. o4o, for Inopexia. — L. H. H.) 

3 Consult Bayer : Gaz. Med., vol. x.. p. 573, 1842 ; and Uhle : Ueber der Typ: 
dominalis der alteren Leut., in Archiv fur pbysiol. Heilkunde. Bd. Ill . 
These authors report striking examples of typhoid fever i: Murchison calls 

attention to the fact that no age is exempt from typhus : from the fifteenth to the 
twentieth year the proportion is U> in KHJ ; from the sixtieth to the sixty-fifth, it is 
2.0 in 100; from the seventieth to the seventy-fifth, it is 1.21 in 100. The cam 



THE DISEASES OF OLD AGE. 25 

I think enough, has been advanced, gentlemen, to convince you that a 
senile pathology does exist. And to offer you a striking example of the 
modification which age may impress on manifestations of disease, we shall 
study, at our next lecture, the febrile state in old age, and endeavor to point 
out the analogies and the differences existing between it and the febrile 
condition in the adult. 

which occurred at the most advanced age was one in a man of eighty-four. Kelapsing 
fever is less frequent than typhus in old age, although several examples of it have 
been observed ; over fifty years the proportion is 6.03 per 100 ; over sixty it is 1 . 6 per 
100. Old women are more exposed to these two diseases than are old men. For 
typhoid fever the proportion is 1.40 per 100 over fifty years ; and 0.5 per 100 over 
sixty. These figures are enough to show that the relative immunity enjoyed by the 
aged in respect to the continued fevers is far from being absolute. — A Treatise on 
Continued Fever in Great Britain, pp 61, 303, and 410. London, 1862. 

Now, as regards phthisis, Vuipian and myself have noticed that tuberculization is 
more frequent in the Salpetriere than is generally supposed. One of Vulpian's stu- 
dents, Mr. Moure ton, in his iaaugural thesis, reports nine cases of acute tuberculosis 
in the aged. Three of the patients were over eighty, and acute phthisis was primary 
in all of these c;;ses except one, — These de Paris. 1863. 

Each year in the Salpetriere we notice some cases of cerebro-spinal meningitis 
foudroyante. Since 1852 I have gathered quite a number of facts of this kind, which 
will be found collected in the thesis of Dr. lnglessis. — Sur quelques Cas de Meningite 
Oerebro spinale observes a la Salpetriere pendant le printemps de 1852. Theses de 
Paris. 1855. 



26 CLINICAL LECTUEES ON 



LECTUEE II. 

THE FEBRILE STATE IN THE AGED. 

Summary. — Want of Reaction in Old Age— Organs seem to Suffer separately— Latent 
Diseases — The Gravest Lesions may pass Unnoticed — Fever in the Aged — What 
is Fever? — Importance of the Clinical Thermometer — Chill in Old People — Tem- 
perature-Curves of Lobar Pneumonia — The Practical Deductions to be made 
thereform — Defervescence, Crises, and Critical Perturbations — Diseases where the 
Temperature is Lowered instead of Elevated. 

Gentlemen : — At the last lecture I endeavored to bring out the particular 
stamp which old age imprints on all morbid manifestations. I then re- 
lied principally on the data of physiology ; but to-day we are to pursue this 
study remaining exclusively on clinical territory. 

Not only does old age have special immunities and j^athological predis- 
positions unknown to the adult, but we also see that, in old age, the gen- 
eral reaction which we commonly meet with in disease has undergone a 
complete transformation. In this period of life the organs seem, as it were, 
to become independent of one another ; they suffer separately, and the 
various lesions to which they may become subject arc scarcely echoed by 
the economy as a whole. Thus do the gravest disorders manifest them- 
selves by slightly marked symptoms ; they may even pass unnoticed, and 
it is in old age that we observe the greatest number of latent diseases. ' 

This point of view, gentlemen, is so important in practice that it de- 
serves to be made more conspicuous ; I shall therefore give you some ap- 
propriate examples of it. 

Let us lay aside for a moment the study of physical signs, whose im- 
portance is elsewhere so great in every respect ; let us forget the difficulties 
which attend auscultation and percussion in old age ; we shall have oc 
to recur thereto later on. Let us attend only to those phenomena of 
sympathetic reaction whose absence, often complete, may certainly be tit 
cause for wonderment. 

Let us take as an example one of the most frequent affections met with 
in this hospital. I mean biliary gravel, which commonly induces in adults 
general phenomena of great intensity. You are acquainted with the for- 
midable aspect of hepatic colic, which occurs with such an array of terrible 
symptoms, which, once seen, are never forgotten. Now, you will learn with 
surprise that in the aged it is often difficult to recognize its symptom 
diminished are they ; at best we only find a little weight in the right hypo- 
chondrium, a few attacks of vomiting, slight jaundice, sometimes delirium 

1 "In advanced age the organs seem to act and suffer separately — their sphere of 
activity appears more restricted. . . . One should never forget that in advam M 
the gravest lesions may coincide with a small number of slight, almost insignificant 
symptoms," — Grisolle : Traite de la Pneumonic First edition, p. 



THE DISEASES OF OLD AGE. 2T 

and cerebral symptoms; and these are more apt to induce error in the di- 
agnosis than to enlighten us as to the nature of the disease. l 

If the biliary passages, when distended by the passage of calculi, show 
such a very slight disposition to induce a general reaction, it is the same in 
the case of the renal excretory passages, which may suffer tne contact of 
urinary gravel almost without pain ; and, in this way, the intense pains of 
nephritic colic are very nearly wholly unknown in old age. 

In another kind of cases we see diabetes occurring in patients of an ad- 
vanced age with very different symptoms from those which characterize it 
in the adult. The urine, often but slightly increased in amount, contains 
sugar only intermittingly ; ' and thirst, that betraying symptom, which 
most frequently puts us on the way of the diagnosis, may be wanting com- 
pletely in the aged with diabetes. 

Following such a statement of facts, you will learn without astonish- 
ment that cancer of the stomach 3 and of the liver, as well as pulmonary 
tuberculosis, 4 may remain in a latent condition during the whole course of 
their development. Such are surprises which the autopsy very often pre- 
pares for us. 

But in lobar (croiqjous) pneumonia, so frequent in this hospital, the al- 
most complete absence of general signs is, more than anywhere else, most 
strikingly exemplified. It is enough to quote, in this connection, a passage 
from the important memoir of Hourmann and Dechambre. 5 

" Old women," say these authors,' "do not even complain of malaise ; 
no one in their dormitories — neither among attendants, house-maids, nor 
neighbors — notices any change in their condition. They get up, make their 
beds, walk about, eat as usual, and afterward, feeling a little tired, they 
totter to their beds and expire. That is what in the Salpetriere is called 
sudden death. The cadaver is opened, and a large portion of the pulmonary 
parenchyma is found suppurating." 

Do not such accounts seem very strange ? Is it not, however, an ac- 
knowledgment that the laws which, in adult life, govern the relationship 
between symptoms and lesions, are completely inverted in the aged ? No, 
indeed ; there is reason for remarking, at once, that these kinds of facts, 
though they may not be called in question, yet always ought to be consid- 
ered as exceptional. And besides, they are not altogether uncommon in 
ordinary pathology. Pneumonia sometimes remains latent in adults, in 

1 " In the Salpetriere infirmary few autopsies are made without there being found a 
greater or smaller number of calculi in the bladder, yet biliary colics are extremely 
rare in the Salpetriere." — Beau : Etudes surTAppareil Spleno-hepatique. Arch.de 
Med., p. 401. April, 1851. 

" . . . . The fact holds good for colic with all its train of painful symptoms ; but 
you must take into account the diminution of sensibility ; and it is not rare to find dull 
pains in the gastro-hepatic region, pains which the patients always ascribe to imaginary 
causes, but which may certainly have been caused by the presence of calculi." — Gil- 
lette : article cited, p. 898. 

I wholly agree with Gillette in this respect, and I may add from personal observa- 
vation that the dull pains may also coincide with the passage of urinary gravel, and 
this much oftener in the old than in adults. 

- Bence- Jones on Intermitting Diabetes, and on Diabetes of Old Age : Medico- 
Chirur. Trans., vol. xxxvi. 1853. 

3 " It is in the aged that we discover those degenerations of the stomach which have 
a deceptive progress, which are accompanied neither by vomiting, violent pains, nor 
by dyspepsia— at least the subjects thereof avow not." — Gillette : loc. cit., p. SOS. 

4 " Phthisis in the aged is notable on account of its latent and insidious form." — 
Gillette : loc. cit., p. 898. 

5 Archives de Medecine, vol. xii., p. 57. 1836. 



28 CLINICAL LECTURES ON 

certain particular conditions of the organism, especially in drunkards. 
One can compare several other grave affections with this same type ; for 
example, who does not know that hemorrhagic small-pox may assume, at 
the outset, favorable appearances, only to be abruptly contradicted by a 
fatal termination ? But it is, above all, in the class of infectious and con- 
tagious fevers that we can affirm facts analogous to these. Thus, in epi- 
demic yellow fever, in the plague, and in typhus fever, there are cases where 
the great damage to the organism reveals itself by no symptom which in 
any way predicts the gravity of the disease. Here the pulse is normal, or 
not far from it ; the tongue is clean ; the skin is cool, or but slightly warm 
in the region of the stomach and liver ; the mind is cheerful, and the bodily 
forces unimpaired. But suddenly attacks of black vomiting set in, and 
death unexpectedly supervenes. An American physician, Dr. Caldwell, to 
whom we are indebted for a fine treatise on yellow fever, applies the name 
wallcing cases to those insidious forms in which the unfortunates, believing 
themselves scarcely unwell, and continuing to carry on their business to the 
last moment of their existence, have been suddenly struck down by death. 1 
These insidious forms, then, do not exclusively belong to senile pathol- 
ogy ; but, if we leave aside these few infrequent cases, and regard only the 
ordinary clinical ones, we are led to recognize the fact thai eneral 

rule, there is a want of con*elation in old age between the local lesion and 
the exhibition of general symptoms. A similar state of affairs exists in 
childhood, as Gillette has ingeniously pointed out to us, J but there it is 
just the reverse. In that period reaction is, as it were, exaggerated and 
tumultuous, and a violent derangement of the functions is very far from 
proving a serious danger. In old age, on the contrary, the organism re- 
mains impassible, so to speak, in the face of the gravest changes. Reaction 
is here, then, defective, even to the extent of total absence ; and hen- 
physician ought to be doubly attentive to. and appreciative of the slightest 
symptoms, unless he wishes to be surprised by completely unforeseen oc- 
currences. 9 

It is now time to leave this very general standpoint we have just taken, 
and to broach at last the question which ought specially to claim our atten- 
tion to-day. We wish to study the febrile state in the aged, comparing it 
with that of the child and the adult ; and, in order to give more precision 
to the ideas we desire to set forth, we shall choose, as the type therefor, 
lobar pneumonia — that disease which is febrile in the highest degree, and 
is common to all ages of life. Its development will enable us to state the 
deviations which age may induce in one of the chief symptoms of the ma- 
jority of acute diseases. 

" Fever/' says Gillette," in a passage where he echoes the opinion of all 



'Med. and Phvs. Mem., containing a Particular Inquiry into the Origin and Na- 
ture of the Late Pestilential Epidemics of the United States. Philadelphia. 1801 

*Loc. cit., p. 873. 

3 It must also be remembered that, in old age. sympathetic phenomena sometimes 
assume an entirely unusual aspect. Thus, pneumonia may assume a masked form, 
and at one time appear as cerebral apoplexy, with complete resolution and coma, and 
at another under the guise of a true hemiplegia, with or without contraction of the 
paralyzed limbs. I particularly emphasize these pneumonic hemiplegia*, of which Yul- 
pian and myself have met several examples. They always terminate fatally, and we 
have been able to convince ourselves that there is no corresponding encephalic change. 
In children, pneumonia may present a cerebral variety characterized by eclampsia or 
coma. 

*Loc. cit, p. 874. 



THE DISEASES OF OLD AGE. 2£ 

the professional writers who had preceded him — " fever in the aged is char- 
acterized by an acceleration of pulse and a dryness of the skin, without 
there being any sensible increase in temperature." He next calls attention 
to the fact that the initial chill is scarcely noticeable, or is wholly wanting, 
and that it is the same with the sweatings. The other accessory phenom- 
ena of the febrile state are, according to the same author, all more or less 
extensively modified ; and finally, the description which he gives offers a 
striking contrast to what, in other periods of life, constitute the appurte- 
nances of the febrile condition. 

Is it an exact picture, and does it faithfully represent the truth ? We 
must acknowledge that it does not absolutely satisfy us ; but, in order to 
justify our restrictions, it becomes necessary to enter into a preliminary 
discussion. 

What is fever ? What is meant by the febrile state ? 

It is hardly necessary to premise, gentlemen, that the definition we 
seek is in all respects descriptive, and that we make no pretensions to pen- 
etrate the ultimate nature of the phenomena we wish to characterize. 

In the days of Hippocrates, at a time when they did not practise the 
examination of the pulse, elevation of temperature was the one and only 
element of fever. Galen's definition is sufficient testimony on that point : 
color prceter naturam, this was the characteristic of the febrile state for that 
great physician. 1 During a long series of ages tradition has respected 
Galen's opinion ; but in time it changed, and we see Boerhaave, under the 
influence of the iatro-mechanical ideas prevailing in his day, declaring that 
"acceleration of the pulse is the only symptom which we always find present 
in fever from beginning to end, and which alone is sufficient for the physi- 
cian to recognize the presence of fever." 2 Since then the question has 
been taken up many times, and settled in many and various ways ; but it 
must certainly be acknowledged that to-day the unanimous testimony of 
modern study has pronounced in favor of the opinion accepted by antiquity. 
On all sides it has been recognized and proclaimed that a rise in animal 
heat is certainly the fundamental event of the febrile state. Among the 
other phenomena that accompany it there is none, not even the accelera- 
tion of the pulse, which appears in such a constant, such an obligatory man- 
ner. Fever does not exist when the temperature remains at the normal 
point, and the pulse may attain the limits of utmost frequency, and still no 
fever may be present. It is sufficient to mention the extreme and excessive 
excitement of the circulatory system noticed in certain cases of arterial 
pulsation, and particularly in the exophthalmic and hysterical cachexia. 3 
Now, can it be said, on the other hand, that fever occurs every time the 
temperature rises ? That is a point on which it is scarcely possible to 
give an opinion to-day. We really observe, however, an elevation in bodily 
heat in those cases which seem foreign to all pyretic reaction : in tetanus, in 
attacks of epilepsy, and in cholera especially at the moment of death ; the 
temperature may then reach 107^-° Fahr. or 109^° Fahr. But there is, no 
doubt, some element which escapes us ; it is always the increase in animal 
heat which predominates in fever, and it may, in many instances, serve to 
measure its intensity. 



1 De different, febrium, cap. i. De g-enerali febrium divisione. There is another 
definition of Galen's, in which the frequency of the pulse is adduced ; but it occurs in 
a less authentic work. 

' l Aphorism 570. 

3 Briquet : Traite de l'Hysterie, p. 326. 



30 CLINICAL LECTUEES ON 

It is the methodical use of a means of investigation unknown to the an- 
cients which has, in great measure, contributed to definitely fix our ideas 
on this question — I refer to the clinical thermometer. Though criticism 
has not spared it, this means of investigation has made its way in our times, 
and we can foresee that the period is not far distant when its general use 
shall have spread throughout the ordinary clinic. 

It is said that the celebrated Swammerdam, of Holland, was the first, in 
the seventeenth century, to think of appreciating by means of the thermom- 
eter the heat of disease. 1 Since that time several physicians have engaged 
in similar methods of observation. In 1754 de Haen called the attention 
of his students to the necessity of substituting the use of the thermometer 
for the application of the hand in determining the bodily temperature. And 
to him also we owe the establishing of an important fact — to which we shall 
very often allude, because it is so frequently observed in the clinic in old 
men — that, at the very moment when the skin of the fever-patient is pallid, 
purple, and cold (pdle, vioiacee et refroidie), in consequence of the contrac- 
tion of the superficial capillar}' vessels, the temperature of the blood rises 
several degrees higher than the normal standard ; and that this is not a 
transient rise, such as occurs in the initial chill of fever, but is, as it ap- 
pears, a permanent one during the whole duration of the febrile state. 

In the past century John Hunter was almost the only author who re- 
sponded to this call. But in our time the labors of Professor Gavarret 
(1839), of Bouillard, Monneret, and some other French physicians, have 
enabled us to appreciate all the clinical import of this means of iim 
tion. Still it is only during the last few years, and in Germany, that any ac- 
tual progress has been realized in this respect. It maybe asserted without 
any exaggeration, that, in the hands of Burensprung, Traube, Michael, and 
Wunderlich pre-eminently, clinical thermometry has undergone a radical 
transformation. The question is no longer, indeed, to ascertain that the 
temperature has risen a few degrees in fever, nor to note its intensity ac- 
cording to the morbid species. The phenomenon must be followed day by 
day — hour by hour, so to speak — from its very commencement to its definite 
termination, and in all the varied phases of its evolution, in order i 
cognizance of its slightest oscillations, and to show that the graphic tra- 
cings obtained by this methodical investigation give constant types for every 
form of disease, with variations which correspond to the most important 
circumstances attending the malady. For this is the only way by which 
one can prove that these tracings have a real clinical importance, or that 
they enable us to follow the course of the morbid process better, perhaps, 
than any other method does, and to recognize its various tq 
thereby, as a consequence, unquestionably furnishing valuable information 
pertaining as much to the diagnosis as to the prognosis. Finally, it must 
be shown that the thermometries! curves are modified according to certain 
rules and certain laws, either as the disease has been left to itself, or has 
been treated by the methodical exhibition of this or that medicinal agent ; 
for we may be allowed to hope that therapeutical experiments may find a 
criterion of almost mathematical precision in the application of this method. 

And this is the complex task imposed upon themselves by the authors 
we have just mentioned ; and though they may not have attained the end 
proposed, it would be rank injustice not to acknowledge that they 1. 
least disseminated many truths along their route. 

The need of similar work seems at last to be understood in Fran 



Kequin. vol. L, p. 91. 



THE DISEASES OF OLD AGE. 31 

well as in England, and many physicians of both these countries are en- 
gaged in this line of investigation. 1 

For nearly three years we have endeavored, as often as has been possi- 
ble, to make those clinical observations we have been speaking of, upon 
the aged patients placed under our charge in this hospital ; for up to that 
time the practice of thermometry had generally been confined to children 
and adults. The results obtained will enable me to present you with a few 
brief considerations upon the modification which temperature undergoes, 
in the senile period of life, during the different phases of development of 
the febrile state, and thus to compare this time of life with the other 
epochs. 

But I am most anxious to have you observe all the advantages which 
accrue from thermometry in the clinic of the aged. It is hardly necessary 
to repeat here that our descriptions will apply chiefly to the fever that ac- 
companies lobar pneumonia, though several allusions will be made to other 
forms of the febrile state. 

I. — Old people seldom have a chill, says Beau, 2 and we have seen that 
Gillette gives very nearly the same opinion. This proposition is much 
too absolute ; for more than once have we witnessed violent and pro- 
longed chills in the aged at the commencement of pneumonia, erysipelas, 
or synocha 3 {continued fever), a very common disease at the Salpetriere 
at certain times of the year. These chills, characterized by convulsive 
trembling, cyanosis, and algidity of the extremities, appear with even a still 
greater intensity in the paroxysms of symptomatic intermittent fever, which 
so often accompanies deep-seated suppuration, attacks of visceral phlebitis, 
and those inflammations of the biliary passages which in old age are so 
readily induced by the presence of hepatic calculi. 4 

And still, in the midst of all these phenomena, at the very moment 
when the external surface of the body preserves all the marks of consider- 
able coldness, the central heat is maintained at a very elevated degree. 
The axillary temperature, it is true, does not enable us to discover all the 
intensity of this reaction, 5 but in the rectum the temperature runs up to 
104° or 105.8° Fahr., as I myself have noticed on many occasions. 

This rapid rise in temperature in the beginning of diseases very closely 
corresponds to what is observed in the case of adults, and, in this one re- 
spect at least, old age yields nothing to youth. But this rapidity of inva- 

1 Consult, in this connection, the excellent theses of Messrs. Maurice (Paris, 1855), 
Spielman (Strasburg, 1850), Hardy (Paris, 1859), and Duclos (Paris, 1864). In Eng- 
land, Sidney Ringer has made important investigations, and these will be found de- 
scribed in Aitken's work. 

2 Etudes Cliniques sur les Maladies des Vieillards : Journal de Beau, p. 292. 1843. 

3 Relapsing fever, according to Tanner and Reynolds. — L. H. H. 

4 If hepatic colics are rare in advanced life, it is, on the other hand, very common 
to see suppuration of the biliary passages caused by calculi, and above all by intra- 
hepatic gravel. This lesion evinces itself externally by an intermittent symptomatic 

fever, in which the beginning of each paroxysm is marked by an intense chill ; in 
the intervals the thermometer often shows the existence of complete apyrexia. 
Death almost always results from such an occurrence as this. Cornil, in the Memoires 
de la Societe de Biologie (1865), has published several cases of this kind which 
were gathered in my service. It is well known that Monneret had already described 
the existence of a fever of the remittent or intermittent type occurring in diseases 
of the liver. — Archives de Med., 1861. 

5 In such cases there almost always exists a difference of a fraction of a degree, 
sometimes even a whole degree, between the axillary and the rectal temperature. 



32 CLINICAL LECTUEES ON 

sion is met with only in certain diseases ; there are others where the febrile 
temperature is reached slowly and gradually ; and to remain within the 
confines of senile pathology, we shall quote as examples, broncho-pneumo- 
nia and mucous fever. 1 Besides, it is rare to find the temperature rising 
to the same degree in these last-named diseases as in lobar pneumonia 
(croupous p.), a fact we shall have frequent occasion to verify. And now, 
gentlemen, let us see what are the characteristics of general reaction in 
that phlegmasia which we have chosen for the type of febrile affections of 
old age. 

II. — A chill is the initial symptom of the disease, which from that mo- 
ment undergoes a regular development. This is the time when it becomes 
interesting to watch, with scrupulous attention, the daily progress, and, by 
means of the thermometer, to ascertain the smallest variations in the ani- 
mal heat ; for, in the majority of cases, they correspond with the greatest 
exactitude to the various phases of the affection. 

A momentary improvement habitually follows the initiatory chill ; the 
temperature sometimes falls more than a degree and a half, and the patient 
experiences a comparative amount of comfort. But this is a deceptive lull, 
and that very evening, or the next morning, the disease proceeds on its 
course. The temperature rises again and reaches 104 Fahr.; and when 
it keeps at this point for several days, you are justified in believing you 
have a severe case to deal with ; but when, on the other hand, it tends to 
fall progressively to 102 Fahr., or even a little below this, the prognosis 
is, relatively speaking, favorable. The figures I have just given you cor- 
respond to the evening temperature, for fever in pneumonia (even lobar 
pneumonia), does not follow a continual, sharply defined course ; there are 
daily remissions which, in the morning, show a thermometries difference 
of nine-tenths of a degree Fahr., on an average. But in catarrhal pneu- 
monia these variations are very much more strongly marked : tin - 
shown by runs of a degree and a half Fahr., two degrees and a half Fahr., 
and even more than this in some instances. Now, if you remember at the 
same time that in this latter disease (lobular j>.) the temperature rises 
slowly, by successive steps, and scarcely ever reaches the height which we 
notice in lobar pneumonia, you will readily comprehend that an inspection 
of the thermometric tracings may often, alone, enable us to distinguish be- 
tween these two diseases, whose differential diagnosis is at times quite dif- 
ficult. 

We have submitted for your inspection a few examples of this kind, 
several of which were taken in our wards. A simple glance at them is 
enough to grasp the differences we have been endeavoring to make mani- 
fest. 

The juxtaposition of these temperature-curves will enable you to com- 
pare at the same time the tracings obtained from the child and the adult, in 
cither the croupous or the catarrhal form of pneumonia, with those taken 
from an aged patient. A rapid glance suffices to show the perfect analogy 
between them. 8 

Among the tracings which we have before us, there are two which are 
intended to bring out in relief the influence exerted upon the v.u-iati. 

1 Catarrhal or mucous fever ; sometimes synonymous with catarrhal pneumonia. 
— L. II. II. 

2 Touching pneumonia in children, we have borrowed the thennomctrical tracings 
from the work of Hugo Ziemssen — Pneumonic des Iliadesalter. Bex 



THE DISEASES OP OLD AGE. 33 







-A -A 


Z-Jh-A 


'EOS 


, v-ntv- 


I t 


1r V 





104° F. 

102V 6 ° F. 

100%° F. 

983/ 5 ° F. 



Fig. 1.— Catarrhal pneumonia in a child. Re- 
covery. (Ziemssen.) 



Days. 


1 


2 


3 


4 


5 


fi 


7 


8 


9 






















105 4 / 5 ° F. 










































A 




















A 


A 




A 












102V5 F. 


\ 


} 


^ 


/i 


A 














v 


V 


v 


1/ 


s* 












V 


V 


V 












98%° F. 







































Fig. 2.— Catarrhal pneumonia in a woman eighty- 
three years old. Death. (Charcot.) 



Days. 3456 78 9 10 11 Days. 1 23 4 5 "6 78 

105«/s° F. 



104° F. 

102V 5 ° F. 
100V F. 

98 3 / 5 ° F. 

96V 6 ° F. 



^ A A 


%$t 


V VI 


T 


4 d 


3 


^^= 


V N. * 







104° F. 
102V 5 ° F. 
100%° F. 
98V 5 ° F. 



• 




-*-.-£>£-*- 


AT 2V 


w- -^ 


Sl 


*\ 


s 


s 





Fig. 3.— Lobar pneumonia in a child three years old. Fig. 4.— Lobar pneumonia in a man thirty-eight 
Recovery. (Ziemssen.) years old. Recovery. (Wunderlich, quoted by 

Aitken.) 



Days. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


105V 5 ° F. 


























A 




' 
















104° F. 




/ 


V-. 






















) 




















102V 5 ° F. 


J 










^ 






















\ 


t 










100 2 / 5 ° F. 














\ 






















V 


A 






98 3 / 5 ° F. 
















V 


\ 


— n 










1 















Fig. 5. — Lobar pneumonia in a woman seventy-five years old. Recovery. (Charcot. 1 ) 

1 In the temperature curve bearing Centigrade degrees, 39° has been, I think, accidentally omitted, and 
3° written instead. I have ventured to make this correction. — L. H. H. 

3 



34 



CLINICAL LECTURES ON 



Days. 
104° F. 

102y 5 ° P. 

100V F. 

98%° F. 
97 7 /io° F- 



4 5 6 7 



9 10 11 12 13 























A 






















1 
















!\ 










fS 










"l 








\, 


'\\ 








1 






!•• 




V 




\ 








I 




i 








\ 


r 


"f 


J 


k 




J 








V 


J 




V 





z a 



Fig. 6.— Lobar pneumonia, treated by dijritali«. in a 
woman seventy-one years old. Death. (Charcot.) 



temperature by therax^eutic agents. In the first of these two drawings 
(Fig. 6), you see that the administration of large doses of digitalis resulted, 
on two different occasions when an exacerbation occurred, in a marked fall 

in temperature. This phenome- 
non, which never *p ontaneous fy 
occurs at this period of the disease, 
can equally well be induced by 
tartar emetic or by bloodletting. 
But such a defervescence is too 
often but a temporary one, and 
every time the administration of 
the medicine is arrested, you ob- 
serve the temperature rise again. 
The second drawing (Fig. 7) 
shows the effect of administering 
rum in draughts of 120 grammes 
to the dose (3| ounces). During 
the first stage of the disease you 
see the t. ore fall slowly 

but progressively under the in- 
fluence of this treatment, only to 
s soon as it is discontinued; 
the disease then assumes its natu- 
ral career and ends in recovery. 
But this is a subject to which, no 
doubt, we shall recur, and dwell upon at greater length in the course of 
our meetings. 

The persistence of a high temperature without well-marked daily varia- 
tions, and its continuance for a certain number of days, constitute important 
clinical characteristics of lobar pneumonia, especially in fteaemZffj 
life. We could mention several 
affections, which, in the 'adult, 
partake of this character (the 
eruptive fevers and exanthe- 
matous typhus, for example). 
But in old people we shall 
rarely find it elsewhere than in 
erysipelas, if we are to rely on 
what we observe here in the 
Salpetriere. Thus you see that 
the clinical importance of this 
fact cannot be exaggerated, es- 
pecially when you remember 
the difficulties habitually op- 
posed in old age to auscultation 
of the chest. And really, a 
diagnosis of pulmonary inflam- 
mation is oftentimes made by 
the thermometer, quite a while 
before the ear has been able to obtain the signs which evidence th> 
ease, by means of a stethoscopic examination. 



104= F. 



102V 6 ° f. 



1K.-V F. 



08%* F. 



96«/ 6 ° F. 





















I 


A 


















1 




• - 


■-, 














1 


1 




\j 
















1 




V s 


, 




■ 










1 












h , 




^_ 




1 








1 


\ 


1 


u 




-* 
















y 


1 








1 






















1 








1 

; 















* 



Fig. 



-Lobar pneumonia in a woman eeventy-rix y« 
treated with nun. Recovery. (Charcot.) 



HI. — It remains for us io describe the minute details which l thermo- 
metrical investigation affords in the period of decline of the febri 



THE DISEASES OF OLD AGE. 35 

the aged, or, as they say in Germany, during the defervescence. Sometimes 
the fall in temperature which marks the return of the normal state is 
effected by successive steps during a period of three or four days, as occurs 
in mucous fever or broncho-pneumonia ; sometimes, on the contrary, it oc- 
curs very rapidly, and in the course of twelve, twenty -four, thirty-six, or 
forty-eight hours, the temperature falls two or three and a half degrees, 
Fahr., or even more than this. At least this is the natural course of affairs 
in lobar pneumonia, when the issue is to be a favorable one. This rapid 
fall of the fever is often preceded by a rapid elevation of temperature, which 
is accompanied by a more or less pronounced and often alarming exacerba- 
tion of the symptoms. This is what used to be called the critical perturba- 
tion. We shall, finally, notice that in defervescence the temperature some- 
times falls below the normal standard, remains so for several hours, in some 
cases during an entire day, afterward to assume definitely the standard 
which corresponds to the state of perfect health. They have then gone be- 
yond the mark, if one may say so ; but only in rare cases have we seen this 
fall of temperature below the normal limits accompanied, in the case of the 
aged, by more or less alarming signs of collapse, which in less advanced 
years quite often distinguish it. 

In many subjects defervescence is the signal for critical phenomena 
which are to decide the disease ; these phenomena occur either just at the 
moment when the temperature falls, or a little later on ; but the latter is 
move frequently the case. (See Fig. 10. *) 

In this respect there is no real difference between old people and 
adults ; except that the sweating-crises, which are so frequent in the mid- 
dle period of life, are not very often observed in old age, whereas critical 
diarrhoea, on the other hand, is quite a common occurrence. 

You can follow the thermometrical tracings (Figs. 1 to 7), which show 
defervescence in the child, the adult, and the aged, and recognize very 
readily that its phenomena are subject to identical laws in all periods of 
life. 

Up to this point we have only taken into consideration those cases which 
terminate in recovery ; but when the disease is to take a fatal turn, the 
temperature, which up to this time has maintained the ordinary limits, 
rises suddenly, within a day, or only within a few hours, one and a half or 
even three and a half degrees Fahr. higher. Under these circumstances, 
in adult life, death usually supervenes- in cases of lobar pneumonia, and 
the same result follows in old age in the vast majority of cases. But in 
the latter we observe, quite often, a mode of termination which is the ex- 
ception in middle life : instead of rising, the temperature progressively falls 
for two or three days, until it reaches 100.4°, or even 99.5° Fahr., at the 
moment of fatal termination. And defervescence to this ominous standard 
is observed not only in those cases where the patient has been counter- 
stimulated, but also in those where the disease has been left to itself. 

The four following figures (8, 9, 10 and 11) exhibit the thermometrical 
tracings of two cases of pneumonia which terminated fatally with an eleva- 
tion of temperature, and one case in which recovery followed. 

The fourth (Fig. 11) is a case where death occurred in the defervescence. 
All the tracings were made here in the Salpetriere. 

Gentlemen, I have shown you, I believe, all the importance of clinical 

1 Consult, in this connection, [the work of Traube : Ueber Krisen und kritische 
Tage. Berlin, 1852. 



36 



CLINICAL LECTURES OX 



thermometry in the study of diseases of old age, arid the utility of the re- 
sults to which it leads, from the triple standpoint of diagnosis, prognosis, 
and treatment. But what I am most anxious to prove to you is that 
febrile phenomena, observed at the most widely separated periods of life, 



Days. 12 3 4 5 

105«/ 5 ° F, 



104' F. 



Days. 
105</ 6 ° F. 



104" F. 



102 V F. 



2 


1 

A 


4 

! 


j 








A 


J A 












TV 












i * 









102 V F. 
100*/»" F. 



Fit;. S. — Lobar pneumonia in a woman eiphty- & /&" F. 

three years old. Death, with elevation of 
temperature. (Charcot.) 

90 V F. 







/ 


a 










1 








52- 




1 








v 




/ 








V\a 


/ 












V 





































































Fio. 9. — Lobar pneumonia in a woman sixty-nine years 
old. Death, with elevation of temperature. (Char- 



Days. 
105V F. 



104" F. 
10»V F. 

100V F. 
US V F. 
96V F. 



5 


1 


7 


8 


9 


10 


11 


II 


13 


14 


15 


U 




















/ 


il 


r~\ 




1 
















y 


\ 


\A 


A 
















: 




V\ 


V 
















1 






y 


\ 




















1 




















































V 




















i 


\ 














1 































































































A 














/ 


\ 




s 


















\ 
















\. 




















H j -r . 














! 


























, 


1 



Fig. 11. — Lobar pneumonia in a womai 
v.ry-five years old. Death 
defervescence, (Charcot.) 



I | 



• i 

: = 
*. 3. 



Firt. 10. — Lobar pneumonia in a woman seventy-fr 
old. Recovery. (Ohwooi.) 



are at bottom the same, and act in obedience to laws which ire idftl 
Just as in the adult, so general reaction exists in the aged : but it is I 
and its manifestations must be sought for in the central I 



economy. 



THE DISEASES OF OLD AGE. 37 

Here, then, it becomes very important to distinguish between the re- 
sults obtained from an axillary and from a rectal thermometrical investi- 
gation. In regard to temperature, the axilla corresponds to the surface of 
the body, and the rectum to the internal viscera. It is true that, in the 
majority of cases, the curves which correspond to the temperature of these 
two parts are very nearly parallel — in the adult we may almost say that they 
coincide ; but, in old age, that which corresponds to the axillary tempera- 
ture is a little lower than that of the rectum. But there are cases, and 
these are most grave, where wide deviations occur. The external tempera- 
ture falls, while that of the central regions of the body rises, and the differ- 
ence between them may be several degrees. Now, in such cases, it is evi- 
dent how very inadequate the results of axillary thermometry would prove, 
and how little we could rely on them exclusively . 

Hitherto, gentlemen, I have scarcely spoken of any diseases, excepting 
those in which the temperature rises above the normal standard. But 
there is a large number of diseases, especially in the period of old age, 
which give rise to inverse phenomena, by inducing an actual lowering of 
the temperature of the central portions of the economy. Without con- 
sidering cholera, 1 whose effects in this regard are universally known, we 
may adduce, as examples, certain diseases of the heart, pericarditis, senile 
gangrene, marasmus, and the various forms of cancer. This algid condi- 
tion is a very grave symptom, and one which demands prompt relief. And 
this algidity cannot be revealed except by means of the thermometer, which, 
consequently, is here called upon to render a new service. 

But to-day I do not wish to broach this subject, for no doubt I shall 
have occasion during our meetings to present you with the result of the 
researches I have undertaken upon the semeiotic value of algidity in old 
age. 2 

1 During the last cholera epidemic which ravaged Paris, I had the opportunity to 
prove that the temperature of the central regions remained at the normal stand- 
ard during the course of the disease, and that it rose on the approach of death, pre- 
cisely as Doyere had already stated. — Mem. de la Societe de Biol., 1866. 

2 See Appendix, Lecture XX. 



38 CLLNTCAL LECTURES ON 



LECTURE III. 

NODULAR RHEUMATISM {fflieumatteme Nouevux) AND GOUT, PATHOLOGICAL 
BLOOD-CONDITIONS OF GOUT. 

Summary. — Frequency of Chronic Articular Rheumatism in the Salp.'triere — Its Re- 
semblance to Gout — The Doctrine of Identity — Silence of the Physicians of Anti- 
quity in this Regard — Necessity of taking up the Preliminary Study of Gout 
before that of Chronic Rheumatism — The Gouty Diathesis— Its General Charac- 
teristics—Regular and Irregular Gout — Acute and Chronic Gout — Pathological 
Blood-conditions of this Affection — Gouty Concretions composed of Urate of 
Soda — Uric Acid's Normal Existence in the Blood — An Excess of it in the Blood 
of the Gouty — The " Thread " Process — Uric Acid not in Excess in the Blood of 
Rheumatic Individuals — Gout not the only Disease which coincides with this 
Alteration — Accessory Changes in the Composition of the Blood in Gout — State of 
the Urine in Acute Gout during the Attacks and the Intervals between them ; in 
Chronic Gout. 

Gentlemen : — In the two preceding lectures we have studied the general 
characteristics which diseases present during the senile period of life ; 
to-day I purpose to invite your attention to one of those chronic affections 
which is most commonly encountered in this hospital. 

I refer to chronic articular rheumatism, which most certainly constitutes 
one of the most common infirmities of females, at least those of the \ 
classes ; indeed, we find it in the proportion of eight in one hundred among 
the infirm women in the ttalpetriere. 

It seems to me, then, that from a practical point of view, this question 
deserves to have your most careful attention, and all the more bo since the 
pathological history of the disease presents many difficulties to be un- 
ravelled, many points to be cleared up. For quite a long period of time 
this apparently unpromising study has been neglected ; and notwithstand- 
ing the importance of several recent works, there yet remains a wide field 
for future progress in this direction. Now, only those observers who are in 
such a hospital as the Salpetriere can undertake a work like this ; but, in 
order to realize this expectation, it is absolutely indispensable that observa- 
tions should be made of a very large number of patients, so that a more 
reliable comparison may be made between the types of chronic articular 
rheumatism, which are often so diverse in character. 

But a difficulty meets us at the very threshold of the question. If 
rheumatism and gout, when regarded in a general manner, coincide in 
many respects, and seem to offer in very many ways a profound analogy, 
it must be acknowledged that it is especially in the chronic form of 
two diseases that the resemblance becomes striking, and then may confuse 
the observer. 

We are, therefore, almost, in spite of ourse lves, led to trench u] 
doctrinal question, and ask ourselves whether, in a general 
are to confound these two affections, or to draw a radical distinction be- 
tween them. 



THE DISEASES OF OLD AGE. 39 

We know that the great physicians of antiquity pronounced themselves 
in favor of the first of these two opinions ; or, to speak more exactly, they 
seem never to have suspected that there was any problem needing their 
solution. Under the name arthritis, or articular disease {articulorum passio), 
they have left us a description of an affection in which we discover at one 
time the characteristics of gout, and at another those of rheumatism ; and 
this ancient tradition was maintained during centuries, until the time when 
BaiUou mollified the primitive acceptation of the word rheumatism and ap- 
plied the term to that group of symptoms which we know to-day under 
the name of acute articular rheumatism. At a little later period chronic 
articular rheumatism, in its turn, acquired an autonomy which had long 
been contended for. 

But the distinction which Baillou made, and which never obtained unan- 
imous assent, is to-day sharply combated by eminent investigators ; and 
although most physicians recognize a profound difference between gout 
and rheumatism, the doctrine of identity has yet found defenders among 
our contemporaries whose names are authorities in science. 

This assent, gentlemen, is in great part founded upon the very nature 
of things. More than once you will be forced to recognize how difficult it 
is to distinguish, at the bedside, gout from rheumatism, above all in their 
chronic forms ; and the name gouty rheumatism, which is often applied to 
those obscure cases which lie upon the confines of the two affections, seems 
to be an implied avowal of powerlessness in this respect. 

However, gentlemen, we are deeply convinced that the two words gout 
and rheumatism correspond to two morbid types which are essentially dis- 
tinct, and which should not be confounded with each other. This is what 
I hope to be able to prove to you in successively studying these two affec- 
tions, so as to bring them, then, close together, and to make a comparison 
between them. It may be that we shall see them unite upon the ground of 
etiology — that is a point to which we shall refer later on ; but, once 
established, they follow a parallel course, and never meet each other. They 
are, as an eminent pathologist has remarked, two branches springing frora 
the same trunk. We accept, provisionally, this ingenious comparison, 
whose exactitude has not as yet been established ; but let us at least be 
permitted to observe that, having once left the common trunk, these two 
branches bring forth very different fruit. 

We shall commence this study, gentlemen, with the history of gout. 
Thanks to the recent works of which gout has been the subject, this affec- 
tion is better known by us in very many respects than is rheumatism ; be- 
sides, we consider it, from several standpoints, as a type of constitutional 
diseases — a model affection. By means of circumstances, unfortunately but 
too exceptional in medicine, we are here acquainted, past all question, with 
a morbific material whose presence gives rise to many and various phe- 
nomena ; we hold a clue to guide us through the labyrinth, and we can 
follow, to a certain point, the logical series of symptoms which successively 
develop under its influence, during a long period of time. We are far 
from assuming that, to-day, we have traced gout to its ultimate essence ; 
first causes, here as everywhere else, elude all our investigations and we 
may only flatter ourselves with having obtained one of the most important 
links in the chain : we have attained a knowledge of that vice of the humors 
upon which depend the principal phenomena that present themselves for 
our observation during the course of this disease. I hope, gentlemen, 
that the numerous details into which we are about to enter will not fatigue 
your kind attention. For, when in the presence of one of those diseases 



40 CLIXICAL LECTUEES ON 

which offer a material basis for our investigations^-gout, syphilis, or sat- 
urnine poisoning, — we must probe the subject to the very bottom ; thus, 
at least, one may hope to dispel, in part, the obscurity which still hangs over 
so many other questions in the domain of medicine. 

First, however, a word concerning the general character of the diathesis 
we are about to study. 

Gout is a chronic and constitutional disease, most often hereditary, and 
always connected with a particular dyscrasia — the presence of an excess of 
uric acid in the blood, constituting, in reality, one of the x^rincipal charac- 
teristics of the affection. It is undoubtedly time that the greater part of 
the morbid manifestations which give gout its particular aspect arise from 
that special condition ; this, for example, takes place in the case of diseased 
articulations. 

And you know, gentlemen, that, from an anatomical standpoint, gouty 
arthropathies are characterized by deposits of urate of soda, either in the 
interior of the joint or in the adjacent structu: 

Independently, however, of these articular affections, and of that pecu- 
liar state of the blood, gout can give rise to numerous and varied visceral 
diseases, sometimes organic, and, again, purely functional. 

There is even reason to believe that, in some instances — quite 
however — the diathesis produces, during the whole period of evolution of 
the disease, only internal derangements of this kind, and never induces 
those external manifestations upon which we usually rely. 

That, gentlemen, was what the ancients called irregular gout, in o] 
tion to regular gout, which corresponds to the classical type of the malady. 

But, even in the latter, we meet with visceral affections, sometimes 
manifesting themselves suddenly in the course of an attack | 
gout — " goutle rctroctdie, remonttc"), or in the intervals (misplaced, a> 
ing gout — "goutte mat placie") ; and sometimes, on the other hand, form- 
ing, by a slow, progressive, and, as it were, latent development, those deep 
organic lesions so often met with in individuals subject to gout (albumi- 
nous nephritis and fatty heart). 

Thus, gentlemen, all that old nomenclature, bristling with Santas 
terms, which the ancients applied to gout — all is unquestionably founded 
upon clinical observation ; in the rigorous study of facts we shall d> 
apparent, regular gout ; and irregular gout as masked, retrocedent, mis- 
placed, etc. It would, no doubt, be useful to institute a reform in this 
language, which has now grown very obsolete ; but we do not yet feel our- 
selves warranted in doing it, and so we must, perforce, continue to make 
use of the terms in vogue among the ancients, while we reserve our privi- 
lege to interpret their exact sense. 

For this reason, gentlemen, you will hear us speak of acute and cA 
gout. Now r , gout is an essentially chronic affection, and can never be acute : 
still, these two names correspond to two of the principal phases of the dis- 
ease. 

Thus, a gouty patient will, at first, suffer from articular attacks, exhib- 
iting all the appearances of an acute affection, which return periodically at 
more or less regular intervals. They may be limited to ■ small number of 
articulations, and more especially to the great toe ; it is then aein 
gout. In acute genera! gout, which offers a great resemblance to rheuma- 
tism, all the articulations may be attacked, even the great ones ; tl... 
example, it is often seen at the same time in the knees, the ellxm - 
the wrists. 



THE DISEASES OF OLD AGE. 41 

In the interval between the attacks, other affections which depend upon 
the gouty diathesis may make their appearance ; such, for example, is the 
dyspepsia which so often torments the gouty ; and such also is gravel, 
which, in certain individuals, manifests itself as alternating with the attacks 
of gout. 

Quite frequently, during a paroxysm of acute gout, we notice the pro- 
duction of functional derangements, which may be attributed to retroces- 
sion of the disease ; but visceral affections, which are connected with appre- 
ciable material lesions, are, on the contrary, very rare. 

Chronic gout, which may supervene from the onset, only comes, in 
general, after several attacks of acute gout. The patient who used to en- 
joy long intervals of repose, sees the attacks becoming more and more 
numerous during the year, and coming nearer and nearer together. Their 
number increases without any diminution of the duration ; and, in the 
end, they meet, they become superimposed — become, after a fashion, sub- 
intrant, to make use of a term borrowed from the history of paludal fevers ; ! 
indeed, the patient is the prey of almost continuous pain, with alternate 
exacerbations and remissions. 

Corresponding to these permanent symptoms are permanent lesions, 
which are, at first, in the joints, and afterward occur in the internal organs ; 
and it is in chronic gout pre-eminently that we find those grave visceral 
affections which, in general, are the direct causes of death. Besides, when 
the disease is prolonged, we finally see that cachectic condition superven- 
ing which ordinarily terminates all great constitutional affections. Then 
do dropsy, anaemia, and marasmus develop ; and then it is that the patient 
sinks into an almost complete state of atony — when nature seems no longer 
to answer to the therapeutic measures which are exhibited to oppose the 
progress of the disease. 

Having stated these preliminary ideas on the subject, we shall enter di- 
rectly upon the history of gout, commencing with the study of those ana- 
tomical alterations which are its necessary attendants ; and since, in this 
general disease, the blood-condition seems to be the all-controlling element, 
we shall first invite your attention to that most important topic. 



Pathological Blood-conditions of Gout. 

Since the time when Scheele discovered lithic acid, which we to-day call 
nric acid, many authorities have thought that this principle might develop, 
during the course of gout, in the fluids of the economy. Wollaston was 
the first to prove that gouty concretions were composed of alkaline urates ; 
and since then Forbes-Murray and Holland in England, Jahn in Germany, 
and Kayer and Cruveilhier in France, have expressed the opinion that in 
gout the blood must contain uric acid. But the honor of furnishing the 
positive demonstration of this fact belongs to Garrod." 

Normally there exist traces of uric acid in the blood ; but during an at- 
tack of gout the blood may contain 0.05 gramme to 0.17 gramme of it in 1,000 
grammes — ( 20 ooo to -g-oVo). But, to make manifest this proportion, it is 
necessary to have recourse to very delicate chemical manipulations, which 
are beyond the domain of the clinic. 

1 4 ' Febris subintrans " — a fever where paroxysms succeed one another without in- 
termissions. — L. H. H. 

- Medico-Chirurgical Transactions, 1848. 



42 CLINICAL LECTURES ON 

There is a simple process, one whose application is much easier, which, 
though not indicating precisely the quantity of uric acid in the blood, 
enables us to establish its presence therein. Put about five grammes of 
serum in a clock-glass (not in a watch-glass, inasmuch as its curvature is 
too marked), add a few drops of acetic acid, and then put in a piece of 
thread. Allow the liquid to remain in a dry place frorn thirty-six to forty- 
eight hours ; then by the aid of the microscope you can determine the pres- 
ence of rhomboidal crystals, which encrust the thread immersed in the 
liquid. These crystals are composed of uric acid. 

In order to obtain this result, certain precautions must be observed- 
First, care must be taken that the serum is fresh, for the presence of albu- 
minoid matter develops a sort of fermentation in it ; the uric acid then de- 
composing into oxalic acid, urea, and allantoin, just as in the presence of 
puce oxide of lead. ' 

Too much drying of the serum must also be avoided, since in that case 
crystals of ammonia and magnesia phosphate would form and appeal' as 
very beautiful vegetations. But, as this is quite a soluble salt, it is suffi- 
cient to add a little water to the preparation in order to dissolve it ; and 
then masses of rhomboidal crystals, composed entirely of uric acid, will be 
seen making their appearance. 

This process, though not sensitive enough to indicate the trace of uric 
acid which exists normally in the blood, is yet amply sufficient for all prac- 
tical needs ; in reality it reveals the presence of mdtk 
part of uric aeid in the blood (Garrod). 

"When blood is not at your disposal, it may be replaced by the serosity 
of a blister, which will give the same reactions, provided care has been 
taken not to apply this revulsive at any place invaded by the gouty innam- 
mation ; for all phlogistic action causes uric acid to disappear. 

It is very easy to understand the clinical importance of this process 
many cases it is an excellent means of di.;_ It also enables us t 

cover under what circumstances an excess of uric acid is produced in the 
blood. This phenomenon exists permanently in cases of chronic gout ; but 
its intensity is augmented during a paroxysm, to fall thereafter below the 
limits previously marking it. In acute gout it does not occur in the inter- 
val between the attacks, at least at the commencement of the dis< 
rod),* but manifests itself anew some time before the onset of the attack. 
Lastly, in cases of ab-articular gout, we notice the appearance of various 
symptoms which seem to be connected with the same condition of affairs, 
since analysis reveals the presence of uric acid in the blood. 

Now, on the contrary, acute articular rheumatism (Garrod), or chronic 
rheumatism (Charcot), is never connected with that particular dya 
and here we find a useful element of diagnosis in doubtful ince it 

then is quite sufficient to apply a blister to the patient or draw a few 
grammes of blood from him, in order to feel assured whether it is to gout 
or rather to rheumatism that the observed phenomena should be ascribed. 

However, this excess of uric acid must not be considered as a pathogno- 
monic symptom of the gouty diathesis ; such a phenomenon occurs in 
Bright's disease and in cases of lead-poisoning. It is. nevertheless, prob- 
able that this particular condition induces a predisposition to gout : at 
least it seems to explain the frequency of this affection in the lead-workers 
of London (Garrod). 



1 I\toe oxide : per- or binoxido. 

1 See Reynolds : A System of Medicine. Ani London. 



THE DISEASES OF OLD AGE. 43 

The presence of uric acid in the humors of the gouty is likewise re- 
vealed by the composition of various fluids, either normal or pathological. 
I have found it in the cerebro-rachidian fluid, and Garrod met with it in 
the serous effusions into the pleural and pericardial sacs. It is not known 
with certainty whether it exists in the intestinal secretions, but it is found 
in the pustular liquid of eczema (Golding Bird), and in the white, powdery 
substance which sometimes forms upon the skin of gouty patients ; this 
powder is composed essentially of urate of soda (Petit, O. Henry). 1 In every 
case it is very certain that sweat, whether spontaneous or induced, does 
not contain a trace of it (Garrod, De Martini, Ubaldini). 2 

"We have yet to ask ourselves the question whether, in gout, the blood 
does not also present other alterations in its chemical constitution. Al- 
though this part of the subject is still quite obscure, it nevertheless seems 
to have been established : 

First. — That the proportion of blood- globules is maintained at the 
normal standard in gout, thus evidently contrasting with rheumatic 
anaemia ; while in chronic gout there is, in the long run, a diminution of 
the globules — this is gouty ansemia. 

Second. — That in acute gout there is augmentation in the fibrin ; the 
bleedings at least, are bufty. 

Third. — That in chronic gout the albumen of the blood diminishes if 
there be a diseased condition of the kidneys, in which case an excess of 
urea will be discovered. 

Fourth. — That the alkalinity of the blood is always diminished, and this 
it is which seems to favor the production and deposition of concretions. 

Fifth. — Lastly, that sometimes the blood contains traces of oxalic acid. 

As a complemental part of this study we should examine into the state 
of the urine in gout ; for the question is, whether uric acid is found there- 
in in a much greater proportion than usual, as has been claimed ; or 
whether, on the other hand, it is in much smaller quantity, as careful 
modern investigations seem to have demonstrated. 

In order to obtain a reliable solution of this question, it is not only 
necessary to estimate the proportional quantity of uric acid contained in 
one specimen of urine, but to find out the total amount of uric acid elimi- 
nated by the kidneys in the interval of twenty-four hours, and this, not 
only during a single day, but for several days, inasmuch as the excretion of 
uric acid by the kidneys is intermittent. 

It is absolutely necessary, then, to have recourse here to a methodical 
analysis ; and one ought to remember that the presence of a free acid in 
the urine, or in a specimen where there is not an abundance of the watery 
part of this fluid, will be accompanied by the formation of those sediments 
to which generally such an exaggerated degree of importance is attached. 

It is after having directed attention to all these sources of error that 
Garrod arrives at the following results : 

In acute gout, during the fit or paroxysm, the urine is scanty and dark 
in color, but the quantity of uric acid excreted in twenty-four hours is al- 
most always considerably less than in the normal state of affairs (0.25 gr. 
instead of 0.50 gr.). There is, thus, a diminution in the excretion of this 
product coincident with an augmentation of its proportion in the blood. 

In the interval between the attacks, the urine was not examined ; still, 
we shall find that gravel is frequent, as likewise are the crystallized de- 

1 Journal de Pharmacie. October, 1841. 

2 Union Medicale, No. 40, p. 24. April, 1860. 



44 CLINICAL LECTURES ON 

posits of uric acid formed before micturition (Rayer); but the occurrence 
of this phenomenon is not sufficient to prove that there is an actual excess 
of uric acid, either in the blood or in the urinary excretions. 

In chronic gout the tendency to diminution increases more and more. 
During an attack the urine is pale, and copious in amount ; so long as the 
disease remains apyretic, it does not form sediments upon being cooled, 
and merely traces of uric acid are found in it. Still, from time to time 
there are unloadings (decharges), during which the urine contains a con- 
siderably greater quantity of this product. 

In the intervals between the attacks these characteristics persist : albu- 
minuria is frequently observed, and sometimes the urine contains fibrinous 
cylinders. 

To sum uj), gentlemen, it is clear that, under the influence of the gouty 
diathesis, there is a superabundance of the urate of soda in the blood and 
in the humor*, to speak in the medical language of ancient days ; urate of 
soda likewise constitutes those articular deposits which at all times have 
been markedly noticed in the gouty. But this excess of uric acid does not 
manifest itself by an augmentation of the renal secretion, but seems, on the 
contrary, to coincide with a faulty elimination. 



THE DISEASES OF OLD AGE. 45 



LECTURE IV. 

PATHOLOGICAL ANATOMY OF GOUT. 

Summary — Local Changes in Gout — Condition of the Articulations — Diarthrodial Car- 
tilage — Deposits of Urate of Soda occupy by Preference those Tissues Deprived 
of Vessels — Condition of the Synovial Membranes and the Ligaments — Tophus 
(Chalk-Stone) ; its Composition — Inflammatory Phenomena — Dry Arthritis — Anky- 
losis — Place of Election of Gout : Articulations which it may Invade — Peri- Ar- 
ticular Tophaceous Concretion — Deep-seated Cutaneous Concretions — Tophus of 
the External Ear — Enumeration of the Principal Points where a Tophus may 
Form. 

Gentlemen : — In the last lecture we have seen that, at all periods of its 
evolution, gout coincides with an excess of uric acid in the blood. 

To-day we are going to show you that the local changes in this disease 
arise, for the most part, from the direct consequences of this general alter- 
ation, and that the deposits which are met with deep within organs or tis- 
sues are almost always formed of urate of soda. 

The knowledge of the changes to which we invite your attention is not 
confined to modern days. Long ago it was known that, in gouty patients, 
tophi and chalky deposits formed around the joints ; but these were looked 
upon as exceptional occurrences, and were thought to be peculiar to the 
gravest and most inveterate cases. It was reserved for Garrod to show that 
the slightest attack of gout leaves an indelible imprint upon the tissues it in- 
vades, and that the latter are forever stamped with its seal. 

Let us begin by studying what occurs in the diseased articulations : 
there we shall see gout manifesting itself by truly peculiar and constant 
anatomical characteristics. 

L — From the very first attack deposits of urate of soda fomi in the ar- 
ticular ' (diarthrodial) cartilage ; 2 they occupy the most superficial portions 
of the cartilage, and are lodged either in the space between the cells, or in 
their very interior — a fact which Cornil and myself have established. They 
are generally located about the centre of this free surface, as far as possible 
from the insertions of the synovial membrane, which stops, as you know, 
at the circumference of the articular cartilages. 

It is not difficult to comprehend the reason of this singular choice. 
The points accessible to the circulation are the least liable to the forma- 
tion of these deposits which occupy preferably those tissues which are de- 
prived of vessels ; now, synovial membranes and bone possess an eminently 
vascular structure, and thus gouty concretions form on the surface of the 
cartilage so as to be separated from the bone, and form at the centre of this- 
surface so as to be removed from the synovial membrane. 

1 Garrod : On Gout, p. 211. London. 1*63. 

- Articular, also called diarthrodial cartilages, and "cartilages of incrustation " 
(cartilage d'encroutement). — L. H. H. 



4(3 CLINICAL LECTURES ON 

At a more advanced period of the disease, when the chronic stage has 
succeeded the acute, the synovial membrane itself then suffers invasion, 
and the appendages of the fringe-like processes at the margin of this mem- 
brane, being less rich in vascular supply, are the first to be attacked ; later 
on the synovial membrane itself presents incrustations. It is then that de- 
posits form in the epithelial cells, according to Professor Eouget ; and the 
whitish sediment or mud — (boue blanchatre) — which is sometimes observed 
in gouty articulations is nothing but urate of soda proceeding from epithe- 
lial desquamation. 

"We know, indeed, that the ligaments themselves at times participate in 
this process of incrustation. But it is not even here that the pathological 
process ceases ; it may go farther and invade parts extraneous to the arti- 
culation; the tendons and the synovial sacs may become the seat of it, and 
when a concretion develops in the adjacent cellular tissue it receives the 
name of tophus, or chalk-stone. Sometimes, you know, it attains a consid- 
erable size. These extra-articular lesions, however, which correspond to a 
more advanced state of saturation, are always secondary to those changes 
in the diarthrodial cartilages, which may exist alone, but which can never 
be absent when deposits of urates have occurred in the circumference of 
the articulation. At least, we know of no case which forms an exception to 
this rule. 

And now let us see what is the composition of the material that con- 
stitutes these deposits. Examined with the naked eye, it appears amor- 
phous, and resembles plaster-of-Paris ; but, viewed microscopically, it seems 
to be entirely formed of needle-like crystals. It is true that you sometimes 
find masses of amorphous matter disseminated throughout the affected 
cartilage ; but Garrod claims that by means of the polariscope you can es- 
tablish the fact that these agglomerations are themselves | I of a 
crystalline structure. 

When acetic acid is employed, rhomboidal crystals of uric acid are pro- 
duced, and it is by means of this reagent that we can prove the jam 
of depositions in the interior of cartilage-cells. Bat we her means 

for determining the chemical composition of these incrustations : if the 
affected cartilage be treated first with cold water, then with alcohol, and 
next with hot water, it becomes perfectly transparent, and the reagents that 
have been used in this washing deposit, upon evaporation, crystals of pure 
urate of soda. These crystals, when incinerated, produce carbonate of soda; 
treated with fuming nitric acid, and then with ammonia, they give rise to 
purpurate of ammonia, or mwrexide, whose color is so character:- 

But we shall not further urge the chemical part of the question ; it 
will be sufficient to remark that the cartilage, when thus rid of its incrus- 
tations, presents a perfectly normal structure, with no change visible either 
under the microscope or to the unaided eye. At least, this is the general 
rule. 

As for the liquid — often muddy — contained in some instances within 
the articular cavity, it quite often has an acid reaction, presenting micro- 
scopically epithelial debris and needle-shaped crystals. 

II. — Let us now point out some other lesions, which, though they are 
not constant, none the less merit a detailed description. 

"When a gouty articulation is opened just after an attack, the synovial 
membrane is almost always found red, injected, and vascularized: but while 
these phenomena never go on to suppuration, an excess of fluid is, how- 
ever, often found within the articular- cavity. 






THE DISEASES OF OLD AGE. 47 

In cases of inveterate gout all the lesions of a dry arthritis may be met 
with at the diseased point; and consumption of the cartilages ("asur"), 
secondary ulcerations and osseous swellings, have all been remarked by 
various observers. Indeed, I have myself seen some cases where they 
were present ; but they are exceptional occurrences, whose nature is as 
yet not well understood, but which deserves a very attentive study. 

Do you see in these peculiar cases a kind of transition between gout 
and rheumatism ? Can it be that they are the results of a kind of com- 
bination of these two diatheses ? Or is it only a question of a simple com- 
plication ? 

This is a question whose answer, it seems to us, ought to be postponed. 

Finally, ankylosis may be the result of the changes which have just 
been described : sometimes it amounts to only a simple rigidity, the result 
of incrustation of the ligaments ; but true osseous ankylosis is also met 
with, as has been remarked by Garrod and by Ranvier. Indeed, this may 
come from the very first attack, as Todd and Professor Trousseau have 
pointed out. 1 

m. — Gout does not impartially choose its seat from all the joints, as 
was well known in the days of remotest antiquity, for the metatarso-pha- 
langeal articulation of the great toe enjoys the unpleasant prerogative of 
most frequently drawing down upon itself the manifestations of this dis- 
ease ; then come the fingers, followed, after a long interval, by the knees 
and the elbows. The hip- and shoulder-joints are usually spared. 

Sometimes, however, the great toe is not attacked by the gout while 
other articulations are being invaded ; and this is a fact of great practical 
importance, since it allows us to understand why general acute gout some- 
times presents such a strong resemblance to acute articular rheumatism, 
and to explain how it is that certain observers have been led to confound 2 
the two. 

It is evident, for example, that an attack of acute gout, occurring simul- 
taneously in the knees and wrists, would be very difficult to distinguish, at 
the bedside, from a purely rheumatic affection. 

Among the rare and exceptional cases we may mention those where gout 
attacks the vertebral column, the temporo-maxillary articulation (Ure), the 
arytenoid cartilages (Garrod), and finally the ossicles of the ear (Harvey) : 
this results in a new species of deafness. 

IV. — From this necroscopic study we shall deduce a number of consid- 
erations, the importance of which, from a clinical standpoint, is incontes- 
table. 

First. — At once let us observe that the incrustation of cartilages is in- 
separable from articular gout, and seems to begin with the first attack. 

Second. — In a gouty patient the diseased joints alone present this lesion 
of their cartilages, and now and then it is found only in a single articula- 
tion. 

Third. — This incrustation of urate of soda goes on independently of the 
paroxysms or attacks, and in the interval between them it may not reveal 
itself upon the exterior of the joint by any appreciable deformity. 

1 Todd : Practical Remarks on Gout, p. 45. London, 1843. Trousseau : Clinique 
Med. de l'Hotel-Dieu, vol. iii., p. 328. 

5 In the original it reads : " amenes a les comprendre." I have taken the liberty 
to substitute confondre in correction of what I deem a printers error, the context cer- 
tainly pointing to confound instead of comprehend. — L. H. H. 



48 CLINICAL LECTURES OX 

Fourth. — This lesion is peculiar to gout, and never occurs in articular 
rheumatism, whether acute or chronic. 

There yet remain the questions : "What relationship subsists between an 
attack of gout and the formation of a deposit ? Is the latter phenomenon 
the cause or the effect of the symptoms which accompany it ? This last is 
a difficult question to answer, and we shall reserve its discussion for 
another time. 

V. — We have seen that deposits of urate of soda form upon the exterior 
of diseased articulations. They are met with : 1st, in the tendons, and more 
particularly in the tendo Achillis ; 2d, upon the periosteum, but never in 
osseous tissue ; 3d, in the serous sacs (the olecranon and patella's) ; 4th, in 
the subcutaneous cellular tissue ; and 5th, even in the deep layers of the 
skin. The last two points especially deserve consideration. 

The subcutaneous depositions which form in the vicinity of joints con- 
stitute a very important part of the symptomatology of chronic gout, for 
they often manifest themselves during life. They are known by the name of 
tophi, tophaceous concretions^ OTchali>stones — terms which are very frequently 
misapplied. They are exclusively given to the peri -art icular collections of 
urate of' soda, and ought never to be employed to designate the osseous 
tumors of chronic articular rheumatism. 

In the earlier stages of their development these chalky masses have a 
soft and doughy consistence ; later on they harden, and acquire a certain 
degree of solidity. From a chemical point of view, they are conipo- 
urate of soda, mingled with the urate and phosphate of Hme. Microscopi- 
cally, they present very tine crystallized needles. 

Their favorite seat is in the hands and upon the surface of extension ; 
but they are equally found about the great toe and at other localities. 
They are ovoid tumors with an irregular surface, sometimes be: 
sometimes having a pedicle, and at times attaining a volume equal to that 
of a pigeon's eg;g ; they are in the immediate vicinity of the joints, without 
exactly resting upon them ; being movable laterally, they do not pn 
reproduce the form and the contour of tl. afl in juxtap. - 

with them. They exert a lateral pressure upon the joints which do* 
always deform them ; they present no symmetry in their mode of distribu- 
tion ; the skin covering them is shiny, sometimes being of a dull white 
color, and with transmitted light you may be able to see the subjacent de- 
posits. 

These various properties enable us to distinguish the tophus from those 
characteristic deformities of nodular rheumatism which we shall atndj 
later on in the course. But we must not overlook the fact that b 
very difficult cases occur, in which there is an angular deviation of the lin- 
gers analogous to that met with in chronic rheumatism. Here the consid- 
eration of the articular deformities alone will not suffice to establish a diag- 
nosis, if no external tophi exist. You must, in that emergency, rely upon 
those general or local phenomena which, taken as a whole, characterize the 
gouty diathesis ; and you may even meet with cases where it will be D 
sary to have recourse to a chemical examination of the blood before arriving 
at absolute certainty in your diagnosis. 

XI. — These concretions which form in the deep layers of the skin, also 
offer, from a practical point of view, a special inter. 

The deposits in the external ear* described by Ideler, Scudai:. 



THE DISEASES OF OLD AGE. 49 

Professor Cruveilhier stand in the foremost rank ; and Garrod lias shown 
how great an advantage may be taken of them, in respect to the clinic. 

The seat of these little concretions is generally upon the edge of the 
helix, but they may occur in the anti-helix or on the internal surface of 
the auricle or pavilion of the ear. They pass through three stages of de- 
velopment : at first soft and pulpy, they next become hard, and form small, 
whitish masses ; finally they may fall off, leaving behind them a small cica- 
trix whose existence may be proven when the tophus itself has disappeared. 

Of 37 cases Garrod found external tophi in 17 ; upon the ear alone in 7 
instances, and upon the ear, and near the joints, 8 times ; once only on the 
line of an articulation was a tophus found, without a coincident, similar de- 
posit in the ear. 

These decisive indications sometimes become manifest very early ; I 
have been able to predict in advance, simply by the presence of a tophus 
in the ear, the outburst of gout in a dyspeptic patient, in whom, neverthe- 
less, articular symptoms had never appeared up to the time when he con- 
sulted me. Garrod witnessed the formation of these concretions in one of 
his patients five years before the appearance of any symptoms in the joints. 1 
In this way one readily understands what importance they have i'rom a 
diagnostic standpoint. 

When concretions upon the external ear are wanting, the following parts 
should be examined : 1st, the eyelids ; 2d, the ake of the nose ; 3d, the 
cheeks ; 4th, the palms of the hands ; 5th, the corpora cavernosa. 

Upon all these points cutaneous depositions have occurred identical with 
those which we have just described. 

It now remains for us to speak of the pathological anatomy of visceral 
gout, and to that we shall devote our next lecture. 

1 These exceptional cases do not, however, invalidate the general rule. Articular 
symptoms almost always precede the formation of these external deposits. 



50 CLINICAL LECTUKES ON 



LECTURE Y. 

PATHOLOGICAL ANATOMY OF VISCERAL GOUT. 

Summary. — Retrocedent Gout ; Functional Lttiont of Goat — Inmost Instances after 
an Autopsy has been made, these seem to arise from Material Changes — Organic 
Lesions most frequently met with in the Viscera of Gouty Subjects — Fatty 
Degeneration of the Heart — Atheroma of the Aorta— Bronchial Lesions — Gouty 
Nephritis : Its Two Distinct Varieties — Gouty Kidney of the English : Lesions 
Corresponding to this Designation — Deposits of Urate of Soda — Bright's Disease — 
Interstitial Nephritis. 

Changes Analogous to Gouty Changes in Animals — Do n Mammals — 

Occur in Certain Birds — Similar Lesions in Reptiles — Experiments of Zalesky — 
Results of Ligation of the Ureters in Different Animals. 

Gentlemen : — If gout were a more common affection in our hospital - 
would i)robably be better Acquainted with the pathological anatc my of the 
visceral lesions that may arise from this i aware, 

the opportunity of making an autopsy of B gouty sub;. rarely i re- 

sents itself in France. The English authors fare much better in thi- 
ter, and they have given us some very in! details concerning the 

subject. It may be stated, however, in a general way. that little is known 
of the whole question, at least wit: the anatomical h - 

Gouty nephritis alone stands as an exception to this rule ; and for this 
reason it behooves us to study it with particular care, after rapidly 

outlined the state of our knowledge touching the other 
tions of gout. 

I. — We shall first consider those sudden modifications, occurring in the 
course of gout, which have received the name of met.. 
sions. 

In such a case one would evidently suppose, upon a t that it is 

only a question of mere superficial lesions, esi>ecially when the symptoms 
are not followed by a fatal issue : it does not seem probable that the dis- 
eased organ could be the locus of deep-seated changes, and one would 
rather be disposed to class derangements of this kind under the head of 
functional lesions. But here the stamp of pathological anatomy is almost 
completely wanting, by very reason of the rapidity with which these B 
toms disappear in the majority ot" Cftf 

Still, we do not always find things happening in this v :h is 

sometimes the result, and one may be called upon to make th< 
In such cases organic lesions have often been dis. .ml. in ti 

gard, we \ vera! observations which are worthy of credit ( 

of these cases, which were accompanied by gastric Bym] I 
under the observation of Dietrich, Perry, and Budd. The pal 
cumbed with the classical symptoms of gout in the stomach ; and an 
matous swelling of the submucous cellular tissue of ;' 
covered, along with more or less marked changes within the mucous 
membrane itself. 



THE DISEASES OF OLD AGE. 51 

In other cases, where the patients rapidly sank during the course of a 
gouty attack or fit, the ordinary lesions of a cerebral hemorrhage have been 
discovered, and sometimes even rupture of the heart has occurred. 

If it were allowable to judge in view of these examples, we would be in- 
duced to believe that, even in those cases where functional derangements 
manifest themselves upon the occasion of gout, they nevertheless corre- 
spond to organic changes less superficial than generally supposed. 

But there are other lesions which seem to be connected with this dis- 
ease, which have been met with in subjects who have suffered from either 
acute or chronic gout, when an intercurrent disease, or the progress of the 
gout itself, has induced a fatal termination. These we shall hastily review. 

A. — The muscular walls of the heart are often affected with fatty de- 
generation. S. Edwards, Lobstein, and some other observers, have found 
urate of soda in valvular concretions, although Garrod contests the accu- 
racy of this statement. 

B. — The aorta is often the seat of atheromatous change ; moreover, 
urate of soda has been discovered in its walls by Bramson, Bence-Jones and 
Landerer. 

C. — Bence-Jones has asserted the experience of urate of soda in the 
walls of the bronchial ramifications. 

D. — Up to the present time no special change has been ascertained to 
to be present in the brain, meninges, or in the encephalic arteries. 

E. — The kidney-changes in gout, ordinarily described under the head 
of gouty nephritis, are to be divided into two varieties. 

In the first place we find the disease described by Bayer under the 
name of goaty nephritis, which may be properly denominated gravel of the 
kidney. It presents the characteristics of chronic interstitial nephritis, but 
is pre-eminently marked by infarctions of fine gravel and uric acid, the 
latter sometimes in a crystalline condition, although larger-sized gravel 
may also be present. These deposits occur ; 1st, on the surface of the kidney 
and deep in the cortical substance ; 2d, in the mammillary elevations and 
papillae ; 3d, in the calices and infundibula ; upon the last-named part the 
concretions are generally large in size. 

These changes may also occur apart from articular gout, but they are 
undoubtedly of very common occurrence in this affection. 

In the second place we have what is properly called gouty nephritis ; 
this is the gouty kidney of English writers. Signalized by De Castelnau in 
1843, it has been excellently described by Todd and Garrod. Anatom- 
ically it is characterized : 

First. — By urate of soda infarctions in the form of white streaks (trai- 
nees blanchdtres), which are found in the tubular substance (never in the cor- 
tical portion), and, in some cases, in the pyramids. Microscopically, they 
appear in the form of crystalline needles, whose seat, according to Garrod, 
is in the spaces between the uriniferous tubules ; although we believe we 
have proved that their starting-point is in the very canal of the uriniferous 
tubules which are obstructed by them. 1 

Second. — It is characterized by concomitant changes within the kidney, 
which correspond to the ordinary lesions of Bright's disease. 

At first there exists a parenchymatous nephritis, 2 which may appear in 

1 Charcot and Cornil : Memoires de la Societe de Biologie. 1864. 
2 Loe. cit. 



52 CLINICAL LECTUEES ON 

one of two different stages. In the first stage the kidney preserves its ordi- 
nary size, but the cortical substance becomes thicker and presents a yellow- 
ish tint. The Malpighian corpuscles are injected, the uriniferous tubules 
are filled with epithelial cells which are distended, opaque, and full of fatty 
or proteid (albuminoid) granulations. 

In the second stage you find atrophy of the cortical substance and that 
granular condition of the kidney belonging peculiarly to Blight's disease. 

But, besides this parenchymatous nephritis, you also meet with the in- 
terstitial nephritis corresponding to the gouty 

This is especially characterized by a thickening of the intertubular 
nective tissue, and a proliferation of nuclei (cells, , The volume of 

the kidney is diminished, and its bu] wrinkled, granular, 

The cortical substance is markedly atrophied. In this 
have never been seen in a waxy condition. 

According to Garrod. I in all cases of ur- 

ate gout where an autopsy has been made ; and t. 
early in the disease, having 
tack. In one case recorded by Iran 

tion occurred only one year ;iftcr ti 

was undoubtedly a viscera] form of the i 

Although the changes in the parenchyn 
excepting in the deposition of in la, from those winch < rial in ordi- 

nary Blight's d sptoms hi cmtj albuminu- 

ria are remarkable on account of 
intensity which they pn at 1 do 1. . dwell i. 

which belongs to symptom 

To this kind of c 
quently figure in the train i^i tl. 

is often aggravated, if not who that pat] 

lion of tlte kidney; and again, o d.tna ifl fcly a COM 

Uraemia is seen in the convulsive 
evidently arises from tl. 
hypertrophy-— both of those may he reckoned among 

quenceS of the renal lesion. 

H — This, gentlemen, finishes the sketch of the anatomical lesions which 
characterize the gouty diathesia Bui 
it profitable to look at certain beta con© 
experimental pathology, which Beam I With a 

powerful light those questions which we ha I those 

also which we shall next oonsidi 

Can gout occur in animals ? And. supposing that it 
it produce results comparable with those it causes in the humai 

In a recent work upon comparative path* 
the negative. He rightly ol 

been designated by this name ought I m d under the head 

rheumatism. At all events, it is incontestable that a disease 
analogous to gout in man, develops, and is characterized, like 

by deposits oi urate of soda in the various tissues of the body. 

We do not find our points of comparison among am. 
be led to suppose from the anal 
in captivity and placed under special conditions. 

You will be aished at finding, in tli< - :reat class' - 

mals, disease presenting some point ( 






THE DISEASES OF OLD AGE. 53 

member that tlie work of disassimilation in them does not produce urea, 
but rather urate of ammonia, as Davy and other chemists have shown. 

Gentlemen, authors of the various treatises upon ornithology will tell 
you that, in certain birds, there may exist lesions closely analogous to 
those of gout. Aldrovandi teaches us that, in the falconidce, tumors made 
up of masses of gypseous matter are liable to form around the toes. This 
is an incurable condition. 

Analogous phenomena occur in parrots. Bertin of Utrecht found, in 
the Fsittacus grandis, urate-tumors in the vicinity of the joints, and similar 
infarctions in the articulations and in the kidneys. 

Lesions of a similar character have been pointed out in the case of rep- 
tiles. Pagenstecher observed the kidneys and joints of the Alligator 
sclerops affected in this way. In ojjhidians these changes may exist in the 
kidney, and in the tortoise Bertin has likewise found both articular and 
renal lesions. 

It is curious thus to meet, in animals but remotely related to man, these 
lesions, which, in all respects, are so strikingly analogous to those of gout. 
But a still more remarkable fact is that these lesions may be artificially in- 
duced by means of physiological experimentation. This is the result of 
an interesting work published at Tubingen, by Zalesky. 

This experimentalist ligated the ureters of chickens, geese and adders 
(Coluber natrix). The first morbid phenomena appeared in from twelve to 
fifteen hours after the operation. Life was prolonged over two or three 
days, and, after death, urate of soda was found in the following viscera : 

First. — The kidneys exhibited it within their tubules, but not in the 
cortical substance. The ureters likewise contained it. 

Second. — The lymphatics, serous membranes, the cellular tissue, and the 
capsules of all the organs, were impregnated with it. 

Third. — The stomach-folhcles contained a remarkable quantity of it. 

Fourth. — It was found in the valves of the heart. 

Fifth. — The joints exhibited, both intra and extra, a considerable accu- 
mulation of this product. 

There was no deposit of urate of soda in the muscles, but the mus- 
cle-juice contained a great deal of uric acid. 

The brain and its membranes seemed to be wholly exempt. 

Concerning the fluids of the economy, the blood contained marked 
quantities of uric acid, and after death clots were found composed of 
alkaline urates. 

Finally, the gall-bladder contained an enormous amount of urate of 
soda, a new coincidence with human pathology ; for in man, according to 
Frerichs, calculi composed of urate of soda are sometimes found in the gall- 
bladder. 

In order to accept unreservedly these data, the experiments must be 
renewed and varied; the effects produced by the ligation of a single ureter, 
for example, must be studied, in order to see whether, after a certain lapse 
of time, the same results will not be produced. It is none the less true, 
however, that Zalesky's experiments possess great interest, and deserve to 
be seriously considered. 

Gentlemen, though this excursion into the domain of comparative 
pathology may seem a little unusual to you in a clinic, you must not be as- 
tonished at the importance which we attach to these facts. We shall meet 
them again at the time when we shall endeavor to argue a physiological 
theory of gout. 



54 CLINICAL LECTURES OX 



LECTURE VI. 

SEMEIOLOGT OF GOUT. -URIC ACID DIA -ACUTE 6 NIC 

GOUT. 

Summary —The Two Principal Forma of Goat ; Aent* and < * 

ways Essentially a Chronic Affection ; but the 
Appearance from the Permanent Comi 
which Collectively Characterize it 
in Solid Matter— M: Gravel-Acute G- 

Articular Pains-General E aaracterwtic. « I '*— 

Secondary Phenomena-Devi;, 
Gout- Asthenic or Atonic Gout- I. 
Transformation of Acute into Chronic 

current Diseases-Chronic Gont following A< ■ «* 

Onset— Development of a Tophus. 

Gentlemen :— Heretofore the anaioi 
sively occupied our attention. \\ l 
the fluids and solids of the 
of this disease, and it now remains for o 
toms arising from the l 

At the beginning of these Iftoturcf we eetnbli 
acute or chronic, gout appears 
which merits a special description. It 
that in every case gout is an t a» otialh 
first attack is but the primitive 
which after this initial paroxysm ma} 
a certain number of years, but whic 
new symptoms. If there d< 

single attack, they are phenomena of ■ fWfj n kind, and cai 

invalidate the general rule. 

Still, the aspect of an acute attack is B 

sented by the disease when in its p 

to respect these expiree I by us.. 

their inexactitude, undoubtedly coir. 
We are about to study in - 

in this way conforming to the universally a 

entering upon the subject, it is p r oper I 

condition which sometimes mai 

lar symptoms, and which, in those who are alre:i< 

often tills in the intervals between its 

recognized as the uric acid diathesis. Let 

condition for a few moments, a condition which is known ohii eana 

of English writers. ' 

1 Todd : Practical Remarks on Gout -oorgv) : <fc the 

Organic Diseases of the Stomach, etc. Load* 



THE DISEASES OF OLD AGE. 00 



Uric Acid Diathesis. 

The chief occurrence — the one that rules the whole situation here — is a 
peculiar dyspepsia, whose ordinary symptoms are flatulence and disten- 
tion of the stomach, and consequently acidity of the stomach and pyrosis. 
At the same time there is a bitter taste in the mouth, with dryness of the 
tongue and supervention of the saburall state. Constipation is almost 
always present in these cases. 

The liver also seems to participate in the derangements of the digestive 
apparatus, and, as it is frequently swollen, it passes below the free margin 
of the ribs. A slightly jaundiced hue is sometimes observed, and the stools, 
besides being rather scanty, become gray and discolored. 

(,)uite pronounced nervous phenomena accompany this dyspeptic condi- 
tion, and may even exist apart from it. You notice spontaneous attacks of 
lassitude, with despondency and headache. Sleep is disturbed, and the pa- 
tients frequently pass into the hypochondriacal state. In women this condi- 
tion may be complicated by manifestations of a distinctly hysterical nature. 

In others, cardiac palpitation and a bronchial catarrh may occur in ad- 
dition. And these phenomena which have n sny great importance 
acquire a greater significance on account of the other circumstances accom- 
panying them. But what pre-eminently characterize this particular con- 
dition of body are the exacerbations it periodically undergoes, and its 
subjection to a most evident influence from errors in diet — a trait in com- 
mon with gout, whose importance should not escape us. 

What i> I >f tiie urinary secretion in such a case? In a general 

way the urine is scantier, but richer in solid matter; it is diminished in 
quantity, but rery acid and high-colored; it is loaded with sediment, which 

usually forms utter voicing of the urine, but which may be already formed 

within the bladder. In such eases crystals of arte acid are very frequently 

met with in the urine; this constitutes Bayer's microscopic graveL 

When (he uric acid diathesis appears before the articular phenomena 
of gout, one may dem cue instances, the existence of an e 

of uric acid in the blood from that moment And. besides, the whole series 
of symptoms we have just been describing occur especially during the in- 
terval between the attacks, when rheumatoid pains will manifest themselves 
in groups of muscles, and in those articulations having a predilection for 
inflammation. These pains appear abruptly in the form of twinges, and 
during the absence of articular inflammation, they constitute one of the 
most characteristic evidences of gout, sometimes, indeed, preceding the 
outburst of the disease. 

Gentlemen, there are, undoubtedly, cases in which this condition of 
affairs may remain unaltered, and in which the predisposition giving rise 
to the uric acid diathesis never receives the last factor in this morbid pro- 
cess, just as gout develops, in certain subjects, at the initial attack or 
paroxysm ; but the general rule is, that upon this pathological foundation 
is developed gout properly so-called, and this development of gout we 
shall now commence to study. 

Acute Gout. 

Let us suppose that a first attack of gout is on the point of breaking 
forth in one who, up to this time, has never felt a touch of this disease. In 
the majority of cases special prodromata announce the coming of the attack ; 



56 CLINICAL LECTUEES ON 

sometimes there will be an extreme exacerbation of all the symptoms re- 
sulting from the uric acid diathesis, which I have just been describing to 
you ; and, at other times, on the contrary, there will be an abnormal feeling 
of well-being, a peculiar excitation. Finally, in a few cases you may ob- 
serve the production of phenomena wholly unknown to the patient's experi- 
ence, as, for example, an angina, a sciatica, or muscular pains. Still, you 
must recollect that in a certain number of cases there may be a complete 
absence of prodromata, the attack then commencing abruptly in an abso- 
lutely unforeseen manner. 

The occurrence of articular pains is rapid and violent, almost always 
taking place during the night. The patient suddenly feels a characteristic 
pain, likened by some to a bite, and by others to a blow from a cudgel ; 
many imagine that they have suffered a sprain, and on the first view the 
diagnosis is somewhat difficult. The most frequent seat of these sensations 
is the metatarsophalangeal articulation of the great toe. Soon n 
and swelling appear at the point attacked ; there is enlargement of the 
veins of the affected member, which assumes a purple color. rding 

to Gairdner, is now and then covered with ecchymoeea. Fluctuation, some- 
times apparent, sometimes real, is developed at the same time ; and when 
real is caused by the presence of an excess of fluid within the articular 
synovial membrane. 

The general symptoms accompanying these local manifestations are 
fever, irregular chills, nervousness, and great irritability; and, finally, a 
marked diminution in the quantity of the urine, which upon coolin _ 
posits a very copious sediment. 

Toward morning the pain and most of the other symptoms rem 
reappear that evening or during the night. This condition oontinui 
five or six days should medicine have been adminisl bt or 

fifteen should no medicines have been employed (G then, 

a kind of chain of short attacks linked one to another, an 
intervals of remission. 

In the first days of the attack marked oedema appears in the inflamed 
parts, soon extending over the whole member, and pitting 
The decline is characterized by superficial desquamation. Ultimately i 
thing is restored to a normal condition ond the patient ei - • . only 

to be broken by the next crisis. 

Thus you see that, to sum up, the salient features of acute gout are the 
following : 

Mrst. — The abrupt invasion and the special character of the pail 
Frenchman, quoted by Watson, 1 comparing the Benaation which he h 
often experienced with the effects of great pressure, said that rheum 
was the first turn of the vise ; but, give it another turn, and you had _ 

Second. — QSderua of the member at the commencement of th 
and desquamation of it toward the decline. 

Third. — Absence of suppuration. 

Fourth. — The special seat of the symptoms, their favorite location being 
the great toe. 

Fifth. — A febrile reaction whose degree of intensity is j 
the number of joints affected, contrary to what is obeerv< 
articular rheumatism. 



1 Principles of Physic, etc. Vol. h\, p. 7 
-I have heard it also put thus: "Screw up the viso ill 
have rheumatism ; give it another turn, and that is gout."-- L. II. H. 



THE DISEASES OF OLD AGE. 57 

And finally, when taking the secondary phenomena into account, the 
most striking occurrence is the relief felt by the patient after the attack ; 
and this feeling of comparative well-being probably corresponds to the 
destruction of a certain quantity of uric acid. 

Along with this change in the general condition, we ought to describe 
the alterations occurring subsequently in the local state of affairs. Follow- 
ing the first attack there is, in the vast majority of cases, no restraint what- 
ever to the articular movements ; but sometimes you notice prolonged 
rigidity of the articulation, or an indefinite persistence of the oedematous 
swelling. These, according to Garrod, are the results of injudicious treat- 
ment — such, for example, as the application of leeches to the affected part. 

In some cases — happily very exceptional ones — ankylosis occurs at the 
commencement (Todd, Trousseau, Garrod); and, in other cases, there are 
premature formations of tophi or chalk-stones. 

This, gentlemen, is the commonest type of an attack of regular acute 
gout. I should undoubtedly have been able to draw a more animated pic- 
ture of it, if I had not restricted myself to follow an analytical order. But 
you can readily console yourselves by reading the immortal description 
left by Sydenham, or the eloquent pages Professor Trousseau has devoted 
to this subject. 

And now, let us see what are the principal deviations which may be pre- 
sented by the regular type I have just been describing. 

Let us first consider the deviations which gout may undergo with regard 
to the situation of the articular symptoms. Usually, or rather, let us say in 
the vast majority of cases, the great toe is the part affected — sometimes of 
one side only, and again of both sides consecutively. Scudamore found 
that, in 512 cases of gout, the great toe was attacked 373 times at the first 
fit, either alone or in company with other joints ; and of these 373 cases 
there were 341 in which the symptoms were mono-articular. 

It is very clear that, from a diagnostic standpoint, the greatest advan- 
tage may be derived from this strange predilection. For in this regard an 
unmistakable difference subsists between gout and articular rheumatism. 

Still, there are cases where the great toe is only affected secondarily, 
the disease primarily appearing at some other point, as, for example, in the 
knee. Traumatic causes seem to play a very important part here, a blow or 
a fall predisposing (as in rheumatism) the injured articulation towards 
becoming the seat of gout ; but we shall return to the subject of etiology 
farther on. 

Exceptional cases do exist where the great toe remains perfectly exempt, 
both at the first and at the subsequent attacks. Garrod describes cases of 
this sort, and I have myself noticed a few of a similar character. Gout, 
then, can be located in the knee or any other joint from the first attack. ■ 

Finally, there is a form of the disease that deserves special attention, 
since it presents the greatest analogy with acute articular rheumatism, at 
least with respect to the symptomatology : I refer to acute primitive general 
gout, which, from its very first attack, invades several joints at the same time ; 
a great number of the articulations, large and small, may be affected simul- 
taneously. Here the attacks are of longer duration, persisting during two 
or three weeks, and may even be prolonged over several months. This is 
the " gout with successive paroxysms " of Professor Trousseau. How many 
times have not these symptoms been attributed to acute articular rheuma- 
tism ? 

But acute gout presents variations not alone with regard to the seat of 
its manifestations ; but the intensity of the principal symptoms, the pain, 



58 CLINICAL LECTURES OX 

the general reaction, may suffer a strange diminution. This is quite fre- 
quently the case with women and debilitated patients, and is the mild, 
atonic, or asthenic form of acute gout, whose progress is generally unfavor- 
able, and which readily passes into the chronic state. 

But, as we have already once observed, gout is essentially a chronic 
affection, even in its acute form. And hence, it is indispensably necessary to 
study the attacks taken in connection with one another, to follow them step 
by step in their repeated returns to the onset, and to describe the charac- 
teristics presented by the successive attacks. 

Return of tine attack. — At the commencement gout seems to accord quite 
long periods of rest to its subjects : only one attack occurs in two or three 
years. Later on the symptoms recur annually, and next tie 
in the year — in the spring and in the fall — a sign that th< i 
been a change in the usual pathological occurrence- 
generally makes its appearance at the close of winter (Trousseau). 

At last the intervening periods grow smaller and smaller, and the at- 
return every third or fourth month. Already the chroi 
entered upon. 

You must recollect, in addition, that accidental conditio 1 
vene or derange this regular progression ; a traumatic lesion, phl< 
an erysipelas sometimes occurs to accelerate the advance of ti. 
or to induce sudden and unexpected returns of it. 

Characteristics of the new attack*. — For quite a long period tin 
striking modification of the symptoms which collectively mark tl 
Restricted to one or two joints, the articular inflammation oontio 
cupy the same locality, while the general symptoms still pn 
degree of intensity, the intervals between the attacks 1 
morbid manifestations. 

However, as the disease pro- 
and it displays a tendency to assume the chronic form. 
large joints are seen to under . md thai 

always the following order : the toes, the ins! 

the hands, the wrists, the elbows, and finally in r and 

the hip. Then the patient, struck by the unquesti . t dilv 

imagines that his disease has changed its nature and lu 
into rheumatism. 

At the same time the attacks, whose duration is now much pos- 

sess less intensity, taking on the subacute form, and 
much more slightly marked febrile reaction. T 
free from morbid phenomena, and the symptoms of abarticular 
more and more pronounced : the patient is now troubled m< n the 

past with dyspepsia, palpitation, and various nervous d< rang* 
word, it might be said that the disease, at first con 
becoming diffuse ; it gains in extent what it loses in d< pth. Bui froi 
very moment it is chronic gout. Let us, then, study the eh . 
this latter disease. 



Chbgbxo Goit. 

This form of gout has for its essential character 
eneral depression of the vital forces of the economy, 
expressions atonic or asthenic gout, applied to it by bosh 



THE DISEASES OF OLD AGE. 59 

in reality a pronounced feebleness and a tendency to a cachectic condition 
always do appear — in different degrees of course — when the disease has 
reached this point. And moreover, intercurrent affections display, in these 
cases, a most exceptional gravity — influenza, pneumonia and typhus have 
here an unusual progress, the last-named disease nearly always proving 
fatal (Schmidtmann, Murchison) ; and in this respect there might be estab- 
lished an analogy between gout and diabetes — a view which, later on, will 
be justified by other points of comparison. 

We know that here there exists a permanent alteration in the blood and 
in the urine, which in certain degree explains to us why the intervals be- 
tween the attacks are full of more or less serious abarticular symptoms, 
such as palpitations, dyspepsia, and nervous derangements. And it is like- 
wise under the influence of this alteration that the tendency to certain 
organic visceral affections seems to be generated, the implicated organs 
being the kidneys, liver, heart, and the vascular system in general. 

But chronic gout, though ordinarily succeeding acute gout, may also 
assume the first-named form from the onset, and in that case it presents 
slightly different characteristics. 

First. — Following acute gout, chronic gout is established very nearly 
permanently in the articulations, though the local symptoms become less 
acute and the pains less intense. And lastly, as I have already observed, 
the upper extremity begins to suffer the invasion of the disease ; now it is 
at this period that you notice articular deformities; it is at this period 
especially that you observe the production of those tophaceous concretions 
which are soon to demand our attention in a very special manner. 

At the same time, the change which has taken place in the constitu- 
tional condition is exhibited during the attack b} r a reaction which has lost 
much of its intensity, and during the intervals by more pronounced symp- 
toms arising in the viscera. 

Second. — When, on the other hand, gout is chronic from the very com- 
mencement, the tophi are seen to form quite early, especially upon the 
hands. This is the stationary, primitive form of gout, in which local symp- 
toms depend almost exclusively upon the presence of deposits of greater or 
less size. 

Here we find grave visceral affections manifesting themselves at an early 
day in a certain number of patients : Todd has observed albuminuria ap- 
pearing two years after the beginning of the disease ; and two years later 
the patient was seized with epileptiform symptoms and died in coma. 

In another patient (reported by Traube), albuminuria existed within 
one year after the first symptoms of gout, and the body was already covered 
with tophi. 

We shall now consider the clinical characteristics of those concretions 
which we already know from an anatomical standpoint. And in fact, the 
tophi, when once formed, possess a certain kind of independent existence, 
that consequently entitles them to a separate study. 

Their diagnostic importance cannot be over-estimated, since they give 
rise to special deformities belonging exclusively to gout ; and, besides this, 
they are much more frequent than used to be imagined : Scudamore says 
you meet them ten times out of a hundred, and even that is frequent ; but 
to-day, taking into account the concretions upon the external ear, their 
existence, according to Garrod, may be affirmed in one-half of all cases. 

Their development, which was so excellently described by Moore in 
1811, has three stages. Following an attack, in an interval of remission, 



60 CLINICAL LECTURES 03" 

and sometimes without any pain, 1 a fluctuating fluid lifts the skin, as has 
been observed by Ccelius Aurelianus. In the second stage, these deposits 
solidify and assume the form of hard, indolent, more or less rounded m 
increasing with every attack, and even during the interval between them. 
And finally, in the third stage, the skin ulcerates, and there is an escape of 
chalky material, frequently in considerable quantity, from the aperture thus 
formed. 

When this elimination occurs without phlegmasic action, the cretaceous 
concretions are left bare ; in England old men with the gout are frequently 
seen to score their points at cards with the tophi covering their I 
which make a white mark upon the gaming-table like that of chalk. At 
other times a more or less intense inflammation is lighted up, and we have 
swelling, redness, then a purplish tint of the skin, and even threat 
gangrene; finally, an opening is made and pus and t 
the latter composed almost wholly of urate of soda, make their escape. 

In some cases this phlegmasia results in the formation of ulcere which 
are very difficult to heal. The urate of soda infiltrating the mesh-wi 
the cellular tissue renders it difficult to clean 
trices also have a tendency to reopen. 

Sometimes the articulations themselves may be encroi but it is 

worthy of remark that this occurrence portends no serious 
patient. 

The flow of this material often leads to local or general relief 
Garrodhas even stated that when attempts hare been made to n 
action by the application of astringents, urticular pains somen 
peared either at the point where the ulceration occurred, or 
distant spot. When it has readied its last phase, goal d< 
whose principal elements are marked anaemia, I 
especially in the lower limbs, and intense depression of the n< 
the patients are incapable of undergoing the least fatigue, and th< 
noise becomes intolerable. 

And here, gentlemen, we finish the clinical history of regular 
This form of gout is pre-eminently eharact. 

vmced, by a marked and frequently exclusive predilection for tl. 
tions. And this is the type which you will meet with oft 
practice, and which will be the easiest for yon I ize. 

We cannot say as much for the anomalous, tin r. the mi 

forms of gout ; for they sometimes assume the 
affections, those farthest removed from the gouty diath 
cian who has failed to become specially vera d in the di 
tins kind, is very liable to commit errors which may involve the 
deplorable consequences. Here, then, is a subject del 
attention, and all the more so since its study will enabl< 
one ol the most essential pointsof difference' be tw, t u ti, 
oi ancient days and that of conteinporarv science. We s 
subject m our next lecture. 



1 I have recorded a case of gout, where the patient could aerer suffer ipt 
S!! f° ne Y r, any point whatever, without the imnu . 
at that spot.— JNote by the Editor. 



THE DISEASES OF OLD AGE. 61 



LECTURE VII. 

SYMPTOMATOLOGY OF VISCERAL GOUT. 

Summary. — Predilection of the Ancients for the Study of Pathological Metamor- 
phosis — Importance of Masked Gout in this Respect — Scepticism of the Moderns — 
Definition of Visceral Gout — Functional Derangements : Organic Lesious — 
Masked, Misplaced, Retrocedent Gout — Can Visceral Gout exist Independently of 
all Articular Disease ? 

Diseases of the Digestive Canal — Spasm of the Oesophagus — Dyspepsia, Cardial- 
gia, Gouty Gastritis — Hepatic Evidences of Gout — The Circulatory Apparatus : 
Lesions of the Heart and Blood-vessels — Sudden Death — Cerebral Manifestations 
of Gout—Its Influences up<m Diseases of the Spinal Cord not jet Demonstrated — 
The Respiratory System : Gouty Asthma — The Urinary Passages : Frequent Dis- 
ease of these in Gout — Functional Derangements of the Kidney— Gouty Nephritis 
— Indication of a few other Abarticular Diseases which accompany Gout. 

Gentlemen : — As I announced at the close of my last lecture, we shall 
now commence the study of visceral gout. This subject, as I have already 
remarked to you, deeply engaged our predecessors, and it will be an easy 
matter for you to comprehend the reason therefor. 

Accustomed to collectice views, and taking but little care to minutely 
analyze clinical facts, the physicians of by-gone centuries always had a 
marked predilection for the study of the metamorphoses which diseases of 
long duration underwent. From Galen to Roderic a Castro, who published 
in the seventeenth century a curious book bearing the singular title Qucb 
ex quibus, and from that time to Lorry, a great number of writers have un- 
dertaken to describe the transformation of diseases (mutationes morborum). 
Gout occupies a prominent position in these works, and is more than once 
invoked when they desire to prove that a disease may assume the most 
diverse forms and still not lose its identity. 

It is a generally recognized fact, to-day, that our predecessors exagger- 
ated the number and the frequency of the transfigurations which patholo- 
gical conditions might undergo. Now, in our times, this study, which of 
old was so flourishing, has fallen somewhat into disuse, or, let us rather 
say, it is regarded from an entirely different standpoint. 

But, particularly concerning masked gout, we must acknowledge that 
the ancients saw it everywhere, even where it did not exist. We cannot, 
however, range ourselves by the side of those physicians who, under the 
influence of the too radical reaction of to-day, have even gone so far as to 
deny the existence of this form of gout ; such scepticism is too arbitrary. 
Visceral gout is a relatively infrequent disease ; but it does exist — at least, 
we hope to prove to you that it does. The only question is to ascertain, 
by careful analysis, of what it consists, and what limits are properly to be 
assigned it. 

Situated as we now are, I do not deem it necessary to vindicate the im- 
portance of this subject in your eyes — it is one which recommends itself 
to your attention from a double standpoint ; for, in regard to general 



62 CLINICAL LECTURES ON 

pathology, the obscure and controverted question of metastasis and retro- 
cession is most intimately connected with this study ; and as to q 
pathology, the history of the visceral manifestations enables us to appre- 
ciate simultaneously the great resemblances uniting gout and rheum . 
and also those differences which separate the two. 

But, before leaving the domain of the clinic to comment 
tion of particular phenomena, it seems indispensably necessary to i 
mine, with as much precision as possible, the meaning of t - ssion 

visceral gout. 

This term must not be indiscriminately applied to all the diseases which 
may occur in a patient with the gout ; ti 
dental, and others having but a very remoi 
modified, it is true, by the nature of the soil in which the . 
they cannot be reckoned in with the direct tion. 

We shall reserve the name vit 
nomena that may develop in our internal organs ud 
influence of the gouty diathesis ; and in this 1 
distinguish two natural groups : the first include 
arising from that general condition ; and I 
lesions which may be evolved under its infltu l 

To the first of these two groin ily applii 

masked, misjriaced, and retrocedent gout — • ed at 

every step in writers on the subject ; while, to giw 
acter to this order of morbid phenom< 
but those visceral affections which, in 

the articular lesions of gout, and play a similar rftle in the path.'! 
drama, if we except the locality tiny choose for their seat 

In order that you may better grasp my idea, allow me t<> 
ainples. An individual who, for a I 
denly suffers an attack of gout, and i- 
is so to all appearances ; but, omv the articttlai 
stomach is again troubled as of old. Tl. 

case of visceral gout, where the stomach f the 

articulations in the series of morbid mai 
after a fashion, to suffer in their stead. In lik< 
patient subject to epileptiform convulsions may b. 
cure of the nervous symptoms d 
several observations of this nature. 

In cases of this kind, the visceral affection - a a purely 

dynamie derangement; or, at best, only a superficial ch 
exists. And, besides, you readily understand how t: 
manifestations is subordinate to the locality they occupy. 

Very rarely, however, do you notice here tl italline d< 

urate of soda, which, in the cartilages and in fibrous 
as it were, the history of previous attacks. And I 
elements may be impregnated with urate of 
described— and still not present crystalline d< | 
essentially mobile in their nature: they appear and d 
they may coexist with, precede, or follow articular s 

majority of cases, they are seen to alternate with thex cases 

where the visceral trouble precedes articular gout, and, f 
shorter time, constitutes the only evidence of t: 
masked (larval, fame) gout is applied to it. \\ 
tollows symptoms occurring in the joints, it is , 



THE DISEASES OF OLD AGE. 63 

vided, always, the metastasis has been brought about by the evident inter- 
vention of some external cause — as, for example, cold. Finally, we say 
that gout has retroceded of itself when the symptoms change their locality 
spontaneously. 

And here we have to solve one of the most difficult problems in the 
study we have undertaken. Can symptoms of visceral gout be present in 
a patient whose joints never have been and never will be diseased? In 
other words : can larval, or masked gout exist independent of articular 
gout ? It seems probable, at least ; and yet how many difficulties crowd 
around its demonstration ! 

Let us observe, however, that these phenomena may be present in one 
born of gouty parents, and who from the very outset is thus evidently pre- 
disposed to gout. Here is the first presumption in favor of the hypothesis 
we have undertaken to defend. In the second place, visceral gout appears 
in one of the forms which it ordinarily assumes, when it coexists with arti- 
cular gout. In the third place, there are eases in which implication of the 
joints shows itself as a rudimentary condition, evinced by painful twinges. 
And lastly, the uric acid diathesis, characterized by the group of phenomena 
which we have previously described, may give such an imprint of au- 
thenticity to these visceral manifestations of gout, that it can scarcely be 
called in question, when once the presence of uric acid i/i the blood has 
been established. 

There now remains the second group, that of organic lesions, which in 
the long run almost always succeed affections of the first kind, and have 
the same situation. Still, we are far from admitting that an absolute dis- 
tinction exists between these two orders of occurrences, while it is very 
reasonable to believe that the functional derangements are but the initial 
stage of those textural changes which give rise to permanent disease. 

It is imperative, gentlemen, that we should reduce the very compli- 
cated nomenclature of gouty affections to the simplest terms ; and to im- 
press these ideas yet more clearly upon your minds, we shall present a 
resume in the following table : 

[FUNCTIONAL i ff'dln-ral (preceding). 

Visceral Gout \ I Rtroctdent (following). 

(^ Anatomical, icitk permanent lesions. 

L — "We shall now study in succession the two forms of visceral gout 
which we have distinguished, in each organ and in each system that can 
become its seat. 

We shall begin with the digestive tract, for it is here that affections of 
this character are especially developed ; and it can be asserted with reason 
that "gout is to the stomach what rheumatism is to the heart." ' 

A. — We shall only say a word concerning quite a rare disease of the 
oesophagus, described by Garrod : this is a spasmodic constriction of the 
tube, obstructing the passage of the alimentary bolus. An attack of gout 
is followed by disappearance of this condition. 

B. — Next in order follows the discussion of gastric gout, a subject 
we have already slightly touched upon when speaking of the chronic dys- 
pepsia of gouty patients, as well of the nervous symptoms which accom- 
panied it. 

Masked (larval) gout of the stomach precedes the attacks or fits, and 

1 Ball : These pour le Concours de l'Agregation, p. 158. 



64 CLINICAL LECTUKES OX 

may even develop before any articular disease : in a very large number of 
subjects the gastric derangements undergo marked improve] a soon 

as the joints become implicated. 

In one patient — a case which I personally observed — the digestive trou- 
bles were present before the first attack of gout ; the diagn 
from the existence of a tophaceous concretion on t: d the 

subsequent progress of the symptoms completely substantiated 
ment. 

In another case there had been only a mingle attack of articular g 
Later on intense dyspepsia occurred, and, after having invoked the 
the regular practitioner to no purpose, the pal : union 

a homceopathist. An unexpected success crowned t; 
ment, and he was already congratulating himself for having 
to the "new medicine," when suddenly h< 1 with goat in the 

foot, thus affording an explanation of the miraculous core. B 
visceral manifestation of the diatl. 

Gout retroceded to tho stomach | from 

masked gout in the gravity it mi 
the opportunity of observing those omin< 
terminate in death. 

Gout, it is claimed, may retroced< 
metastasis of Guilbert. But much d 
induced by the intervention of a dirt 
the disease is broken by some violent emotion, by an atl 
or by ill-timed treatment : the patient, urg< d by hie unendui 
is imprudent enough to plunge the aff 
Parry), or to administer to himself some b 
colchicum (Trousseau, Potton de ] 
and swelling of the joints subside, he already felicil 

treatment he has resorted to. when the formidable ut in 

the stomach are suddenly s< rth. 

It is expedient to distinguish, at this point, with ' 
two symptomatic varieties. In ti 
in a cardialgic or spasmodic form : there is int. 
sure, together with a feeling of cramps in I 
same time marked distention of the stomach 
tacks of vomiting which are frequently uncontrollable, end 
grave general condition. Then algidity and cold s\\ 
pulse becomes small, frequent and in 

exhibited. In cases like these, according to Cullen, stimulation ! 
is to be employed, and alcohol in lar 

^ In the second case the difl - an inilamin . There 

is intense epigastric pain, especially on pi 
vomiting occur, the matters being almost black, or a 
a more or less intense febrile movement, and folio- 
comes a condition of general prostration. Stimu 
ployed here, bloodletting being the treatment commended in these cases. 

\A here the general health is very poor, all I 
denly disappears, either under the influence of the | 
tion, or spontaneously with the gouty inflammation returnii 
toe. There is a general belief in the intliu - 
cations to the joint first affected, to recall to that spot a 
to have been displaced : but there are scarcely any vi 
to be iound in books corroborating the usefulm - 



THE DISEASES OF OLD AGE. 65 

But science has recorded eight or ten instances where these symptoms 
have ended in death. 

At the post-mortem examinations which have from time to time been 
made, a thickening of the submucous cellular-tissue was discovered ; the 
mucous membrane of the stomach was cedematous and covered with hem- 
orrhagic erosions, and the cavity of the organ in some cases contained a 
black fluid. These lesions, collectively considered, seem to indicate that a 
change had already taken place at some distant period, notwithstanding 
the sudden occurrence of the disease. 

But, fortunately, these terrible cases are quite rare. Scudamore men- 
tions only two or three of them, and Garrod and Brinton never met with 
one. Quite recently Budd and Dittrich published two such cases. 

But, in a much milder form, gout in the stomach is quite a common 
disease ; it is chiefly met with in cases of asthenia and gouty cachexia, and 
in individuals who have abused specifics and the application of leeches 
and cold. 

It may be asked, however, if the existence of this disease has not been 
too readily admitted in a certain number of patients. It is unquestion- 
ably very easy for errors in diagnosis to be made here ; for hepatic or 
renal colic, the digestive derangements accompanying albuminuria, and 
perhaps even poisoning from certain remedies (from colchicum in partic- 
ular) — all these have more than once simulated gout in the stomach. A 
simple attack of indigestion, abruptly occurring in a gouty patient may 
possibly be mistaken for an attack of retrocedent gout, on account of the 
gravity often assumed by the symptoms, because of the special predisposi- 
tion induced by the uric acid diathesis. Thus, Watson remarks that we 
should say "pork in the stomach, instead of gout in the stomach." This 
scepticism has even gone so far as to almost absolutely deny the existence 
of gout in the stomach, and Brinton, after a long discussion of this ques- 
tion, finally concludes that a little gastric irritability may possibly exist in 
gouty subjects, but that anything beyond this must be regarded simply as 
a coincidence. 

We profess the opposite opinion in this respect, and after assigning a 
large share to errors in diagnosis, we believe that the various diseases 
which may be summoned to do duty in this regard are yet far from ac- 
counting for all the jmenomena. We have previously seen that physiolo- 
gical experimentation succeeded in producing in animals occurrences that 
were analogous to those of the gouty diathesis ; and in such cases we know 
that the gastric juices and the stomach-follicles become charged with urate 
of soda. While not pretending to call upon identical conditions to account 
for the phenomena of gout in the stomach, we think that superficial lesions 
can very readily be developed in the digestive apparatus under the influ- 
ence of retrocession ; and this view is perfectly confirmed by the results of 
autopsies made upon gouty patients who for a long period of time have 
suffered from their digestive organs. In such cases as these Todd has 
often discovered an enormous dilatation of the stomach, and Brinton has 
himself verified these results by personal observations ; this is the paralyzed 
and enfeebled condition of the stomach which Scudamore long since de- 
scribed as existing in chronic cases of this disease. 

And besides, it is probable that, after a time, permanent lesions are 
developed in subjects liable to these apparently functional manifestations ; 
and the fatal cases to which we have just alluded seem to afford the proof 
of it. 

C. — Corresponding to the two forms of gout in the stomach, above de- 
5 



06 CLINICAL LECTURES OX 

scribed, are two forms of intestinal dyspepsia : the first is characterized by 
attacks of spasmodic colic, and the second is a true enteritis. These phe- 
nomena may exist separately, or be joined to the various derangements of 
which the stomach may become the seat. 

n.— " The liver is rarely liealthy in gout " says Scudamore, and daily 
observation tends to demonstrate the truth of this opinion. 

There are, undoubtedly, diseases of the liver associated with gouty 
pepsia, and also transient enlargements of this organ which precede the 
attack, such as were observed by Scudamore, Galtier Boissiere, and Martin- 
Magron. 

But we are not yet absolutely certain whether there are permanent dis- 
eases of the liver which are the result of the gouty diathesis. Scudamore 
thinks that, in the end, the spleno-hepatic system feels the innuer 
gout, and becomes the seat of permanent disease. Besides, from the labors 
of modern physiologists, we know that the liver and spleen are probably 
the organs in which uric acid is formed. 

Still the anatomical character of this visceral affection (if it < 
mains as yet unknown to us ; and the lesions in the liver met with in [ 
subjects are almost always the results of alcoholisn. 

Biliary gravel, however, is sometimes coii. ith the uric 

diathesis and gout (Prout, Budd, Wunderlkh, WiUemin), tad 
then you may meet with uric acid calculi in the gall-bladder, accord; 
Stockhardt, Faber, and Frerichs. Still, the patients in whom ti 
tions were discovered might have been gouty. 

m. — The influence of gout upon diseases of the heart cannot 1 
verted. But we are not concerned here, M in rheumatism, with sod 

ditis, pericarditis, or valvular IssJ when occurr. 

the gouty, seem to be caused especially by 1 i slooholi - 

The dominant condition here is a fatty 
tissue of the heart. Stokes, Quain, Gfsizdner, sod Qarrod all unite in affirm- 
ing the existence of this state of affairs. 

In the beginning this affection is present only in a sligl.- 
merely manifests itself by functional derangen 
and feebleness and irregularity of the pul 
retrocession is quite infrequent (Scudamoi rrodi. tl. 

a few cases of it, and death has even resulted from cardiac implication. In 
these cases, however, the lesions we are about to study had alread\ 
developed. 

In the second stage, we find fatty degeneration of the I v nrp- 

tomsof this disease are always the same, whatever 1 
Garrod). They simulate functional derangement, end, 
being only slightly marked, the diagi rived at 

of exclusion. 

The cardiac impulse is feeble, almost absent ; the fl dull, 

and sometimes there is a niurniur resulting from fattv d 
tenser muscles of the valves. The precordial dulness '.v in- 

creased; the pulse is soft, compressible, intermit' 
ceedingly slow, especially during an attack or par 
pulsations); and finally, some have described I 
existing m those individuals whose cardiac muscular t:- 
this alteration. 

The rational symptoms are also quits capable of d 






THE DISEASES OF OLD AGE. 67 

The attacks develop by paroxysms ; there are violent palpitation, dyspnoea, 
and a tendency to syncope ; and cerebral symptoms are seen to occur, 
assuming the guise of an apoplexy, although no intracranial hemorrhage 
has taken place (Law, Stokes). Sharp pains develop about the precordial 
region and shoot down the arm, thus simulating angina pectoris, which is 
itself frequently regarded as a disease of gouty origin. 

Finally, sudden death is a very frequent occurrence in these cases : thus, 
in 83 cases of fatty degeneration collected by Quain, death took place 
unexpectedly in 54, viz. : 28 times from rupture of the heart and 26 from 
syncope. In many of these observations the subjects were gouty patients. 

It is evident, then, that a goodly number of cases where death was 
attributed to gout in, or retroceded to the heart, were but cases of fatty de- 
generation of the organ. Quain and Gairdner witnessed death produced 
without rupture under these circumstances, while death from rupture was 
observed by Cheyne and Latham. The fatal termination has often occurred 
during an attack of gout, this latter condition seeming to act here as an 
incentive to the cardiac crisis. 

Lastly, let us note that an atheromatous condition of the arteries, very 
frequently coexisting with these cardiac lesions, may give rise to cerebral 
hemorrhages, in which case true, and not false apoplexy, is observed. 

IV. — Our ideas concerning the connection between multiple arthropa- 
thies and diseases of the nervous system have undergone a definite change — 
most occurrences of this kind used to be attributed to gout ; but to-day, 
rheumatism, through the researches of modern investigators, has been 
accorded the first place. Nevertheless, gout still retains its share in it, 
though it is interesting to notice that the two diseases have, in this respect, 
a parallel progression, and that all forms of cerebral rheumatism are found 
again in gout. 

Thus, the rheumatismal headaches described by Van Swieten, and more 
recently studied by Gubler, have their counterpart in the gouty cephalalgia 
which have so long been known, and which, in later times, have been so care- 
fully described by L} r nch, ' Garrod, and Trousseau. Acute delirium, or the 
meningitic form of cerebral rheumatism, occurs also in gouty patients, ac- 
cording to Scudamore. Rheumatismal apoplexy, or the apoplectic variety 
of cerebral rheumatism, appears in the form of stupor in gout, according 
to Lynch and Professor Trousseau. 

The convulsions manifesting themselves during the course of encephalic 
rheumatism are likewise present in gout ; though in rheumatism they 
especially assume the form of chorea, while in gout they are rather epilepti- 
form in character, as Van Swieten, Todd, and Garrod have observed. 

And, finally, we know the existence of a rheumatismal lunacy, which has 
been studied by Burrows, Griesinger, and Mesnet ; and the same is true 
for gout, according to Garrod. Lunacy, however, in the latter disease is 
rare, at least in France — Baillarger, whose experience is authoritative in 
these matters, having informed us that he has never met with a single 
instance of it. 

Just here let me remark, while pointing out a difference : that aphasia 
which is never present in rheumatism, (if we except cardiac diseases and 
secondary embolism), is met with, on the other hand, in gout. It must be 

1 We recommend to our readers the memoir of Lynch as deserving of attention : 
Some Remarks on the Metastasis of Diseased Action to the Brain in Grout, etc. Dub- 
lin Quarterly Journal, p. 276. 1856. 



68 CLIXICAL LECTURES ON 

confessed, too that encephalic derangements are, in general, less grave in 
gout than in rheumatism, that their alternation with articular phenomena is 
more marked, that retrocession is more palpable, and finally, that although 
there often exists a masked (larval) cerebral gout, this is very rarely the 
case in rheumatism. 

Cerebral symptoms of gout must not be confounded with delirium 
tremens occurring at the moment of the attack (Mareet), with the delirium 
which appears in acute intercurrent affections, or finally, with the symp- 
toms which dyspepsia, cardiac lesions, and anemia develop on the part of 
the nervous system with much greater frequency in gout than in rheuma- 
tism. In this regard, prolonged observation, and an attentive study of the 
patient during a long period of time are the only means by which all error 
can be avoided. 

V. — The influence of gout upon diseases of the spinal cord is still a 
mooted question. Todd and Garrod speak of the appearance of - 
symptoms, a sort of paralysis alternating with the attacks ; but 
not confound a lesion of the spinal cord with that in which 

follows intense paroxysms of articular gout, and which l iiilate 

actual paraplegia. 

True, Graves has reported a cat . upon an air 

a hardened and shrivelled condition of the curd v. .: this 

example does not appear to us to be quit' | must 

not be forgotten that if there do exist medullary diseases assoc: 
gout and rheumatism, which is as v< t anpfOfi are, undoubtedly, 

strongly marked articular d iiiently to 

lesions of the spinal cord, even if these be of traumatic origin.' 

VI. — The respiratory apparatus may lik. mie the seat of certain 

gouty manifestations, and these we shall rapidly pass in rev 

First. — Gouty asthma. — Among thoracic affections damnin g of this ap- 
pellation, there is one which corresponds to t 

nervous; the lungs are perfectly free during thi I between the 

attacks, and there is an evident alternation between the I tnd articu- 

lar symptoms. 

Dr. Vigla has reported a very interesting example of this kind to the 
" Medical Society of the Hospit:. 

There is, however, a second form of gouty asthma, arising from r* 
nent lesions and which especially co-exists with emphysema: in 
recognize here alternate exacerbations and remissio: 

disappearance and return of articular symptoms. These cases are quite 
rare : Patissier saw only 2 out of 8 Garrod, 1 out of 40 ; and 1 1 

Salter, to whom we owe a treatise on asthma, also repot* in^le case 

of it. 

Second. — Some of the ancient writ nty plearifl 

was probably a simple gouty pleurodynia. 

Third. — Is there a gouty pneumonia? It has been i some 

observers, but authenticated cases are yet wanting. Scudam 
seen gout manifest itself after the disappear;. 



To-day it certainly has been demonstrated that there h ■ rheummtismal mjdt» 
meningitis. Two observations a: 
hier's service furnish irrefragable proof on this point. 

• Ball : These de Concours pour V Abrogation -'.ft. 



THE DISEASES OF OLD AGE. 69 

question arises whether this be not a fortuitous coincidence. And, accord- 
ing to the same authority, these two diseases may always coexist without 
exercising any influence over each other. We shall soon recur to this point. 

VLT. — Diseases of the urinary passages are quite frequent in gout, and 
at a certain phase of the disease they become almost the rule. They are, 
on the contrary, rare in the various forms of chronic articular rheumatism. 
And herein we discover a characteristic distinction of a not uninteresting 
nature. 

It is necessary, however, to eliminate from the domain of visceral gout, 
in accordance with the rules which we have hitherto followed, everything 
pertaining to calculi and uric gravel, whether renal or vesical. It is true 
that these occurrences are frequent among the gouty, but they do not ex- 
clusively belong to the diathesis. 

Still, there are urinary diseases traceable directly to gout, and these we 
shall now describe. 

A. — The kidneys may suffer a transient functional derangement, present- 
ing striking analogies with articular gout. This occurs in less advanced 
periods of the disease, having for its symptoms a sharp but transitory pain, 
manifestly alternating with articular gout, and which may have its seat in 
either kidney, accompanied by an albuminuria of short duration. It may 
be that during the entire course of this conrplication there is no emission 
of gravel. 

This is not an exceptional manifestation of gout ; Garrod has observed 
several examples of it, and I have myself, with Dr. Clin, seen one case. 
This patient was a physician, and therefore could give descriptions of the 
phenomena he had experienced, worthy of reliance. 

B. — Permanent disease of the kidneys becomes almost the rule in 
•chronic gout ; in this case there is an albuminous nephritis, presenting ana- 
tomical characteristics which leave no doubt as to their origin, namely, 
infarctions of urate of soda in the renal parenchyma. We have already 
described these changes when speaking of pathological anatomy. 

Once established, gouty albuminous nephritis differs but slightly, in re- 
spect to symptomatology, from ordinary Bright's disease. The urine is 
generally found clear and with but little color, containing a var3 T ing, al- 
though almost always a small quantity of albumen, only a trifling amount 
of urea and salt, and exhibiting under the microscope fibrinous cylinders, 
covered with epithelial cells or loaded with granulations. There may be 
oedema of the face and lower limbs, though this symptom is very frequently 
absent. As in Bright's disease, so here we find dyspepsia and diarrhoea ; 
but, as we have already hinted, the progress of the malady is slower and 
its prognosis less grave than in albuminous nephritis properly so called. 

Nevertheless, uraemia has sometimes been observed to occur in the 
course of this disease ; Basham, Todd, Dechamps (of Bordeaux), and other 
investigators have recorded several examples of it. Some years ago I 
called attention to this point myself, and Fournier has shown the impor- 
tance of it in his remarkable these de concours (prize thesis) upon uraemia. 

C — A vesical gout has been described by various authors : Scudamore 
speaks of it, and Todd has endeavored to set forth its characteristics ; ' in- 
deed, a large number of those cases which the English designate by the 
name of irritable bladder ought to be ascribed to this. 



] Todd : Clinical Lectures on Certain Diseases of the Urinary Organs, p. 359. 
London, 1857. 



70 CLINICAL LECTURES ON" 

At the commencement it is merely a question of a transient affection — 
precisely as we saw occurring in the case of the kidneys — merely a dynamic 
derangement, characterized by sudden and violent pain in the bladder, by 
tenesmus, and by a flow of blood and muco-pus from the urethra, even in 
the absence of all calculous complications (Todd). These phenomena may 
alternate with the articular disease. 

But at a more advanced stage there is a permanent lesion, with catarrh 
of the bladder and other phenomena of that kind. Professor Laugier was 
good enough to communicate a case to me proving the reality of vesical 
gout, independent of all gravel complication. 

D. — A gouty urethritis, with escape of pus from the urethra, has finally 
been mentioned ; but have not the writers (Scudaniore in particular) 
allowed themselves to be imposed upon ? Perhaps it was a case of blennor- 
rhagic arthritis — such, at least, is the interpretation which may be given to 
some of Scudamore's observations. 

Vm — Abarticular — non-visceral — gout. — Independent of the internal 
diseases that may be developed during the course of gout, there are other 
manifestations of the same disease, which, though not in-fading ii * 
organs, are yet localized elsewhere than in the joints : they are seen oc 
ing the muscles, the nerves, the skin, and some other portions of the 
economy. 

A. — In the first group we shall place phenomena of this kind which 
belong to ligaments, tendons, and fibrous tissue in 

We have previously established the fact that, when the articular (diar- 
throdial) cartilages have been saturated with urate of soda, the 
and tendons are then observed to become impregnated with that a 
The symptoms of this condition of affairs are generally merged i 
of articular gout, though they may sometimes plat] 

pendent role. It is well known, for example, that the fibrous tissue in front 
of the patella (pre-rotular) may be the seat of pains that are strik 
analogous to those of acute gout ; this is Bayer s pre mtu Han govt. It n 
asked, then, if gout can exist in a larval or masked form in tendons and liga- 
ments ; can it precede, or can it wholly take the place of articular gout \ This 
is still an obscure point, and one demanding new ill mitigation 

B. — Muscles.— Gouty subjects frequently experience painful cramps in 
the muscles of the extremities during an attack of the malady. They suffer 
very often from lumbago, and may even feel very intense pain 
points in the chest- wall ; these are* probably in the intercostal musei 
in the fibrous tissue of the thoracic panetee (gouty pleurodynia). 
patients very often designate these sensations by the nam. matic 

2>ains, although in reality they belong to gout. 

C ~ Serves.— Pain along* the course of nerve-trunks, partieularlv of 
the sciatic and trifacial, is also known to be present daring the i -out. 

Its characteristics are an abrupt appearance and a similar departure, alter- 
nating with articular' symptoms. 

T>.— Cutaneous affections.— Brodie and Civiale bug since observed an 
evident relationship existing between psoriasis, gravel, and uric acid calculi. 
It is certain that psoriasis may often be met with in those bekmgmfl 
gouty family, and that it may coexist with gout in one and t indi- 

vidual. This fact has been placed completelv out of question bv th, 
servations ; of Holland, Garrod, and Bayer. Eczema has liken . seen 

to alternate with the most characteristic attacks of goat 

buch, for the time being, are the only cutaneous diseases whose oomlft- 



THE DISEASES OF OLD AGE. 71 

tion with gout is authentically established. But, under the title arthritides, 
Bazin and his school have collected a great number of different exanthemata 
arising from rheumatism and gout, two diseases which they blend into 
one — arthritis. It must be confessed that the observations they present in 
support of these opinions are not by any means all that could be desired, 
and that gout is here left completely in the background. The cases which 
Bazin collected belong exclusively to rheumatism. 

E. — Ocular affections. — Morgagni has already described the conjunc- 
tivitis sometimes occurring in the course of the first attack of gout, and 
concurrent observations have been made by several authors succeeding 
him, but of all the ocular diseases associated with gout, the one which de- 
serves, in the highest degree, to be joined to the diathesis is certainly 
iritis. Lawrence and Wardrop report cases where the alternation of iritis 
and distinctly marked gouty attacks could not be called into question ; and 
Professor Laugier communicated a case to me where this phenomenon was 
perfectly exhibited. And it is very remarkable indeed to see the iris thus 
affected in gout, the more so since we know that in articular rheumat- 
ism and in subacute, nodular and blennorrhagic (gonorrhceal) rheumatism 
especially, the same symptoms are induced. Lastly, Garrod, in a recent 
article ' has described a gouty affection of the eye, to which attention had 
not yet been called — we mean inflammation of the sclerotic, with whitish 
deposits of urate of soda upon the surface of this structure. 

F. — Diseases of the auditory apparatus. — We have already dwelt so long 
upon tophaceous concretions of the external ear, that there is no necessity 
of again returning to that subject ; and we have likewise pointed out the 
alterations in the ossicles of the ear. Now, it seems certain to us that pa- 
tients suffering from chronic gout are liable to become deaf ; and it would 
be interesting to be able to class this new species of deafness along with 
the lesions we have just been describing, but as we know nothing posi- 
tively in this connection, new investigations are necessary to fix our ideas 
upon this point. 

Here we shall end the history of abarticular and of visceral gout, and 
in our next lecture we shall take up some diseases that offer a certain de- 
gree of relationship to gout. 

1 Reynolds : System of Medicine. Art. Gout, by A. B. Garrod. 



72 CLINICAL LECTUKES ON 



LECTURE Till. 

CONCOMITANT DISEASES OF GOUT. 

Summary. — Conditions seemingly Allied to the Gouty Diathesis — Uric Anthrax — 
Grave Phlegmonous Inflammations and Erysipelas — Dry Gangrene — Intercurrent 
Diseases in Gout — Its Affinity with Diabetes — Greater Of 'jueney < : 

Relation — Diabetes, Obesity and Gout frequently met with, if not in the Same 
Individual, at least in Different Members of the Same Family — Observations in 
Support of this — Practical Results — Gravel — Urinary Concretions — L'ric Acid — 
Oxalic Acid — Formation of a Uric Acid Sediment not always Proof of Augment- 
ation in the Secretion of this Acid — Gravel sometimes Associated with the I 
ence of an Excess of Uric Acid in the Blood — Real or Boppwoi ■ of Gout, 

Scrofula, and Phthisis; of Gout and Cancer; of Gout and lib- 

Gentlemen : — At that portion of our course where I thought : 
ent to give the history of ab-articular B, it would ha \ 

ture in me to dwell upou certain occurrences which likewis to be 

more or less directly associated with the gouty diathl - 
now arrived when it is desirable to Bay I few words con hem. 

I. — A peculiar predisposition to dangeroufl phlegmonous intlamn. 
(p. de mauvaise nature) and to Bphace] had long ago bet 

served in diseases which induce a profound change in the constitution of 
the blood (crusts). 

Albuminous nephritis is an example of this kind sipe- 

las or diffuse phlegmon in regions either inriltr y, or as a 

result of incision or puncture, is frequently seen to occur in | 
ing from albuminuria. On this account, punctures and BCarincationa, which 
in other dropsies are a means of relief, are in thlfl 
indicated (Rayer). 

Diabetes offers us a second example of this unfortunate \ tion. 

English physicians had long since noticed that anthrax, dr\ e and 

diffuse phlegmon supervened with the utmost readiness in di i 
jects, and Marchal (de Calvi), unaware of the labors of his pn 
had the merit of calling attention to this point, which, prior to his time, 
had scarcely been studied in France. 

Now we shall give an account of an analogous series of phenomena 
occurring in the uric acid diathesis and in confirmed gout. 

This pathological coincidence, which already had been adv 
scribed by Morgagni, Thompson, Schonlein, Ure, Carmiehael. and 1 
in our times been demonstrated through the labors 
who has concisely divided diabetic symptoms from 
gout — a work which has been accomplished by none oi 



1 Morgagni: De sedib. et causis morborum. lib. iv <eq. A. R. 

Thompson : Histology of a Case of Dry liangrone. in Medio -Chinuf. Trans... 
xin., p. 178. 1827. Schonlein: Patholog. und Therapie. p. I iii. The author 



THE DISEASES OF OLD AGE. 73 

Cases of this kind, which arise from the uric acid diathesis, may be 
divided into three principal classes : 

First. — The uric acid anthrax is considered as accidental by Garrod and 
Trousseau when it occurs before the appearance of gout ; but, when pres- 
ent during the course of the disease, a symptom of this kind seems to 
arise from the gouty diathesis. Ledwich and Marchal (de Calvi) have re- 
ported several such cases. ' 

Second. — Prout has described the dangerous low phlegmon and erysip- 
elas that may occur in gouty patients. 2 Besides, the operation for cataract 
is known to succeed poorly in these individuals, since the eye almost always 
becomes inflamed. 3 We may associate with these phenomena an instance 
of suppuration of the eye-ball in a case of chronic gout, 4 and one of faulty 
consolidation of fractures. In a case in which there was a fracture of the 
external malleolus, an attack of gout was developed, and then the fragments 
separated, ulceration setting in and the bone became denuded ; but when 
the attack ended, everything was restored to its proper form. 5 

Third. — Dry gangrene, described by Carmichael, Eayer, and Marchal (de 
Calvi) occurs especially in those debilitated patients who are attacked with 
the chronic form of gout and in whom tophi or chalk-stones exist. 

II. — Let us now direct our attention to the intercurrent diseases of 

£ out \ 

We are no longer dealing with affections subordinate to the gouty dia- 
thesis, but with actual complications that occur during the course of the 
malady. In what way are intercurrent diseases modified by gout ? In 
this regard we may institute a comparison between Bright's disease, dia- 
betes, and the present subject of our consideration. Indeed, gout has con- 
sequences resulting from traumatism such as we have just been describing 
to you, and thus we observe in that fact one point of union between these 
three conditions. 

According to Prout, phlegmasia) frequently assume an adynamic form 
in patients who are gouty, especially if they are also strumous or obese : 
in this manner, he says, the greater number of them die. 7 And here isan- 

attributes to arterial ossification that gangrene of the extremities which, according to 
him, is so frequently observed in gout. Al. Ure: Researches on Gout. Medic. Times, 
Vol. iii , p. 145. 1845. Carmichael: Dublin Quart. Journ., Vol. ii., p. 383. 1846. 
Prout: Stomach and Renal Diseases, p. 211. 1848. Marchal (de Calvi): Recherches 
sur les Accidents Diabetiques. Paris, 1^04. 

1 Trousseau : Clin. Med., Vol. iii. Garrod : On Gout. Second edition. London, 
p. 285. 18(53. Ledwich: Dublin Med. Journ., p. 43. Vol. xxv. Marchal {de Calvi) : 
Loc. cit., pp. 38, 283. 

* Loc. cit., p. 213. 3 W. Budd : Library of Medicine, Vol. v., p. 213. 

4 Critchett : Mad. Times, Vol. i , p. 62. 1853. 

6 O'Reilly : American Medical Times, p. 39. 

6 Carmichael: Loc. cit. Rayer: Communication Orale. Marchal: Loc. cit. 

1 As this passage has frequently been quoted in the course of the lectures, I shall 
give it verbatim : 

" It is not rare to meet with this coincidence (uric acid gravel and diabetes) in 
obese individuals of mature years, whose temperament is both gouty and strumous, 
and it ought always to cause the physician great solicitude. I have ascertained that 
such patients succumb, in general, to some visceral inflammation as sudden as it is 
violent, and which rapidly takes on the adynamic type. Besides, they seem exposed 
to grave forms of erysipelas and to diffuse phlegmon. Finally, in most of the cases 
which I have seen terminate fataUy, either from spontaneous diffuse inflammation, or 
from that induced by simple puncture, the uriue had from time to time contained 
sugar, and had deposited uric acid concretions and gravel." — Prout: Stomach and 
Renal Diseases, p. 211. 1848. 



74 clinical lectup.es ox 

other point by which we can approximate it to albuminuria and diabetes. 
Typhus is an exceptionally grave affection in gouty subjects ; according to 
Schmidtmann and Murchison, it is always fatal. ' And syphilis, according 
to Wells, is very serious when occurring along with gout ; it is very apt to 
take on a scorbutic character. 2 

These occurrences, peculiar to the gouty cachexia, are to be explained, 
according to Garrod, by the impermeability of the kidneys. 3 A rapid 
sue-metamorphosis sometimes demands an enormous elimination, and this 
cannot take place when renal excretion is insufficient. But it is probable 
that this is a more complex problem than the English writer sappoa 
and the crasis of the blood ought to play a great part therein. Y\'e can at 
least say that, under the influence of such a diathesis, the mechanical, 
physical and chemical phenomena of life ought to proceed with much 
greater difficulty than in the normal state of affa: 

When, however, no cachexia is present, the termination of these dis- 
eases is far from being so fatal, and things go on in almost the same v 
as when the ordinary conditions exist. But, it must be r« marked, inflam- 
matory accidents almost always arouse the gouty predisposition, and give 
rise to an attack. We have already described the effect of traumatism in 
this connection. Concerning phlegmasia, we may distinguish three 

First. — The intercurrent disease (pneumonia, pleurisy, 
las) persists for a longer or shorter time, and then gout suddenly i 
Scudamore and Day report several instances of this eneraDj 

this appearance of gout is regarded as a favoral 

gout. The same thing is known to occasionally occur in rheumatism. 
The question should then be asked, if, in such a cireunistance. the outb 
of an attack has not been induced by the intercurrent die 
been the case, then the appearance of gout would not be a critical phe- 
nomenon. 

Second. — The inflammatory disease pursues it- 
with gout, without experiencing any noteworthy modification, 
sometimes seen in the case of angina and pneumonia.* 

Third. — There is an abrupt suppression of all external phenomei: 
gout at the moment the intercurrent inaladv is developed. This is a m 
grave symptom, and we should endeavor to recall the gout toward the 
tremities, though, in most instances, this results in complete failure. 

. HI.— Special characteristics ere presented by the action of certain D 
maments in gouty subjects, as, c> priori; one 'would be led to imsgi 
Thus, lead, when exhibited in a medicaments dose to arrest a hemorrh;. 
produced rapid impregnation of the svstem with this metal, accompai . 1 
by the bluish line along the free margin of the gums, and attacks of had- 
cohc. And , according to Garrod and Price-Jones, mercunj induces sal: 

The gouty diathesis, by reason of its frequent association with renal diseases is 
a very serious complication of typhus. I have never seen reo -*- 

22^ London 1862 typhus -"- Murchison ; A Tr ^ise on Continued Fever?, etc.. p. 

eventu. —Schmidtmann : Obser. . Vol. iii , p 370 

3r^ e \ : Pra S i ? , S 0bservations on Gout, etc.. p. 87. London, 
garrod: Reynolds' System, p. 855 

1849 SC p d ft?J e : ^ ^ P - *h Day : Disea ^ s of Advanced Lit, 

tion Y^^ : f ^^ m ^ tla ^^^^,Olm.^S^ K<4 °- l^rry: Collecl 

6 Scudamore ': Loc. cit . rrod . 0r , 



i 



THE DISEASES OF OLD AGE. 75 

tion much more speedily in gout than in other conditions ; ' and I may- 
add that opium should "be administered with the utmost caution to those 
subject to chronic gout, when they present any indication of renal disease. 
In these cases this drug is seen to produce cerebral symptoms out of all 
proportion to the dose exhibited. 2 

Let me point out another interesting fact — one belonging to the same 
order of ideas — namely, the failure to eliminate turpentine from the uri- 
nary passages. Hahn (quoted by Guilbert) administered this drug for 
seventeen months to a gouty patient without causing that characteristic 
odor of the urine which commonly occurs in similar instances. Was this 
patient suffering from albuminuria ? 3 

IV. — We shall now consider those concomitant diseases of gout which 
present a more intimate relationship to that affection than those which we 
have just dwelt upon, and which are more evidently associated with the 
group of modifications the economy undergoes. 

Hunter laid it down as a rule, that, when one diathesis invades our or- 
ganism, no other general disease can exist concurrently with it ; in other 
words, a constitutional disorder, when once it is established in an individ- 
ual, admits of no rival. 

From this principle arose the doctrine of antagonisms — a doctrine un- 
doubtedly exaggerated by the Viennese school (Rokitansky, Engel), but 
which, nevertheless, is founded in truth. 

Still, along with antagonisms, there certainly are affinities; and it is of 
these relations especially that we desire knowledge and insight. 

A. — Gout and diabetes. — The idea of a more or less direct connection 
between diabetes and gout can scarcely be traced back more than two score 
years. Scudamore, far from suspecting this affinity, holds that these two- 
diseases arise from distinctly opposite causes. But a German author — 
Stosch, of Berlin — who published (18*28) "A Treatise on Diabetes," describes 
therein a metastatic diabetes which occurred after the cessation of gout, and 
in connection therewith quotes two English writers, Whytt and Fisher. 
Two years later Neumann records the occurrence of a symptomatic diabetes 
in gout. 4 

At a later period, Prout, who seems to have touched on all questions of 
this kind, places attacks of gout and rheumatism among the most frequent 
causes of diabetes. "Nothing is more common," he says, in another place, 
" than to find a little sugar in the urine of gouty patients, although they 
remain unconscious of it until the ordinary symptoms of diabetes — poly- 
uria, thirst, emaciation — openly declare themselves." 5 Another English 
author, Bence-Jones, has likewise observed that uric acid gravel predisposes- 
to diabetes. 6 

In France, Bayer has frequently remarked to his students the connec- 
tion subsisting between uric acid gravel, gout, and diabetes. You can con- 
sult, in this connection, the thesis of M. A. Contour, 7 and the lectures of 
Claude Bernard. This eminent physiologist has, in fact, stated that dia- 

1 Garrod : Loc. cit., p. 354. Price-Jones: Medical Times. Vol. i., p. 66. 1855. 

2 Todd : Clinical Lectures on Urinary Diseases, p. 343. 1857. Charcot : Gaz, 
Medic, Nos. 36, 38, and 39. 

3 Guilbert : De la Goutte, p. 100. 1820. 

4 Pathologic Vol. vi., p. 607. 
5 Prout: Loc. cit., pp. 33, 34. 
6 Marchal {de Calvi) : Loc. cit., p. 233. 

7 Contour : Theses de Paris, p. 49. 1844. 



76 CLINICAL LECTURES OX 

betes may alternate -with the symptoms of some other disease, and particu- 
larly with attacks of gout and rheumatism. 1 

We had an opportunity ourselves to observe a case which completely 
confirms the statements of Claude Bernard. A man, fifty-six years of age, 
who had been suffering from gout for a long time, had succeeded in di- 
minishing the intensity of the attacks, and finally, in nearly making them 
disappear altogether, by using — rather say abusing— a specific remedy 
(liqueur de Laville) ; 2 but, following a slight attack which he promptly re- 
pressed, appeared thirst, polyuria, increased appetite, emaciation, weakness, 
and the other characteristic phenomena of diabetes. "When this patient 
consulted us for the first time, the urine contained a considerable quantity 
of sugar. An appropriate diet continued for over a year produced a marked 
improvement in his condition, though, the diabetes having considerably 
diminished, a few mild attacks of gout reappeared. 

Marchal (de Calui) has likewise been engaged in discussing the affinity 
between these various diseases, as regards diabetic gangrene, since 1866. 
Some time later he published a work where this subject is treated with re- 
markable ability. 3 

According to this distinguished author, there is a uric acid or gouty 
diabetes, and this conclusion is in conformity with previous observations, 
and with absolute reality. But Marchal (de Calci) may be accused per- 
haps of having extended the domain of this form of diabetes too far, and, 
indeed, that of the uric acid diathesis in general. The considerations which 
he presents in this respect are hardly applicable, in France at least, to any 
but the favored class of society. 

It cannot be questioned but that an affinity exists between diabetes on 
the one hand, and gout and uric acid gravel on the other ; although the fre- 
quency of this relationship varies according to the kind of people in whom 
we observe the occurrences. In this way Griesinger who has studied 
diabetes among all classes of society, found gout in three out of two h • 
and twenty-five diabetic subjects; 4 Dr. Seegen, on the contrary, practising 
medicine at the springs of Carlsbad, and where the patients consequently 
belong to the higher walks of life, met with three cases of gout among 
twenty-one diabetic individuals. The proportion is thus seen to vary from 
one-tenth to one-seventy-fifth. 5 

Nevertheless, we must not be restricted to the registration of 
where gout is transformed into diabetes in the same individual ; but the 
hereditary transmission of symptoms must likewise be studied, and also 
their distribution among different members of the same family, as in the 
case of diseases of the nervous system, where this method has met with so 
much success. 

It is very rare to find gout and confirmed diabetes coexisting in the 
same individual ; but these two diseases alternate with and 
other. Uric acid gravel or gout opens the scene ; and then, usually, gout 

1 Lemons de Physiologie Experimental, etc, p. 436. 18oo : "Diabetes alter- 
nants." 

_ 2 Dr. Laville's anti-gout liquid and pills. Active principle of liquid probablv vora- 
tna— certainly a powerful remedy or poison ; teaspoonful in water. Pills I I 
•of soda and physalin ; two a day with meals. Shorten attacks at expense of he'alth. 
— L. H. H. 

3 L'Union Medicate, No. 29. 185(3. Recherches sur les Accidents Diabetiques, etc : 
loc. at, pp. 409, 469. 1864. 

^Griesinger : Studien liber Diabetes. Arcbiv fur phvsiol. Heilkunde, p. It. 

« P. Seegen : Beitriige zur Casuistick des Meliturie. Yirchow's Archiv. VoL xxi. , 
Vol. xxx. 1864. * 






THE DISEASES OP OLD AGE. 



77 



vanishes the moment diabetes makes its appearance. Rayer had already 
observed that gout changed into diabetes, and Garrod says in these very 
words : " Gout stops ivhen diabetes appears." ' 

Let me add that obesity frequently precedes the development of gout. 

In cases such as those to which we have just alluded, the prognosis is 
sometimes as grave as in ordinary diabetes, and phthisis pulmonalis and 
symptoms of gangrene suddenly occur. Still it must be acknowledged that 
gouty diabetes is in general relatively benignant, especially if the patient 
follow a suitable diet. Then it is that diabetes is latent (Prout). I might 
cite cases where a cure seemed to coincide with a return of gravel or gout, 
and this caused Prout to say that the appearance of uric acid gravel in dia- 
betes is a favorable sign ; 2 nevertheless, these two diseases may coexist and 
yet not mutually improve. 



We shall now regard the analogy between gout and diabetes, consid- 
ered in a family composed of several members ; and thus we notice a father 
who is gouty, diabetic, and phthisical, beget a gouty son (Billard de Corbi- 
gny 3 ) ; or, again, a diabetic father have a gouty son (personal observation). 

We had an opportunity, ourselves to witness a very remarkable case of 
this kind, which Dr. Real communicated to us, and where gout, scrofula, 
diabetes, and obesity were seen manifesting themselves in the majority of 
the members of the same family. This observation is here reduced to 
tabular form : 

Table I. 



Father, brewer, distiller. . . 

Mother 

First son, brewer 

Second son, brewer 

Third son 

Fourth son, alcoholic habits 

Fifth son 



A daughter 

Daughter of the latter. 



A colossus. 



Lymphatic Sciatica. 



Scrofula, ' Articular | „ 
Keratitis rheumatism, f ; UDesu y- 



Diabetes. 



Died ptliisical (48 
years old). 



Diabetes at 50 J S 



Gout at 25 Obesity at 35 Diabetes . 



Lymphatic Gout at 30 Obesity Diabetes. 

Obesity . . 



Keratitis . . Gout Obesity at 35 

Gout Obesity 

Gout Obesity 



Diabetes . 



old). 

Died in delirium. 

Died of an accident. 

Died of cirrhosis. 

Died phthisical (48' 
years old). 

Still living. 

Still living. 



There is evidently a more or less intimate connection between these dif- 
ferent diseases which are thus reproduced, in various degrees, in all the 
members of the same family ; and I have noticed the following combina- 
tion : 

Table II. 



Gouty father . 



f First son — gravel. 
1 Second son — diabetes 
| Third son — gout 
^ Daughter — ; 



Examples of this kind could easily be multiplied, but I think enough 



A. B. Garrod: Reynolds' System of Medicine. Vol. i., p. 825. London, 18G6. See 
: Gulstonian Lectures on Diabetes, in the British Journal, p. 319. 1878. 
Loc. cat., p. 25. » Gaz. des Hopitaux, p. 212. 1852. 



78 CLINICAL LECTUKES OX 

has been said to show you that there is a correlation between the uric acid 
diathesis, diabetes, and gout, which is governed by laws as yet unknown. 

It is easy to appreciate what are the practical deductions from these 
data. The urine of the gouty must, necessarily, be carefully examined ; and 
when this particular variety of diabetes shall have been recognized, a method 
of treatment must be established in accordance with its origin. 

B. — Gout and gravel. — The uric acid diathesis includes gout in all its 
aspects, and hence it is not surprising that gravel, so often a manifestation 
of the diathesis, should very frequently be met with in goutv pati* 
The bond which unites these two diseases has been act • «1 in all 

times. "You have gravel and I have gout," wrote 
Moms, "we have espoused two sist- lenham, Murray and Morgl 

described this affinity, which seems to us beyond all dispute. 

Still there is, at the same time, a certain ai 
conditions ; it is rare, indeed, to meet them simultaneously, for thev rather 
tend to succeed each other in alternation. Tin- moei 
is for gravel to precede gout and to diss] D the Utt 

but the converse may be observed, and in some cast - 

appears when gravel is established. I once witness. md. 

Besides, when gout and grave] coexist is oee, 

as is too often the case, that they are simul- 
frequently accumulates for a long time in t; 
from the organ, thus giving rise to the Bjmpfa 

It is important to notice that the chemii 
cretions is not always the same ii. 
urate of ammonia may also be pn Bent, and 
of oxalate of lime. And oxalic gravel is lik* 
gravel, since uric acid, as you know, may 1>. 
urea, allanto'm, and oxalic acid. 

These variations in the nature of nrinar 
In those gouty patients subject to calculus." 
the concretions formed of concentric 1 which m 

oxalates were alternately deposited, thus clearly \ 
successively occurred in the composition of 1 1 

Finally, let me remark that that the 

blood, sweat and urine of gouty subjects. 5 at | 
gravel manifests itself —another proof of the 
these different morbid phenomena. 

I think, however, that it should be mentioned here that : 
in the urine, a short time after its emifi 
amorphous mates or uric acid in the crystalli 
prove that the excretion of this acid is absolutely i 
diminution in the watery part of the urine and 
are sumcient conditions for inducing precipitation of I 

out any real increase in the amount of uric acid. ( I we 

know to-day, thanks to the labor of Bart, Is.' that in reserves 

pertect limpidity for a long time after its emission m 
ableproportion of uric acid. To know the trm m 

1 Scudamore : Loc. cit, p. 531 
Hxarrod : On Gout. Loc. cit p 187 



THE DISEASES OF OLD AGE. 79 

such a case, it is indispensable to analyze the total amount of urine passed 
during the twenty-four hours, and even to repeat this examination for the 
five or six days succeeding, according to the teachings of Parkes and 
Banke ; ' for it has been proved that the excretion of uric acid undergoes 
the most marked variations, not only at different periods of the same day, 
but also from one day to another. 

It seems, however, very reasonable to admit that uric acid exists in the 
blood in excess, when urinary sediments form, not after, but before emis- 
sion ; and still more so when gravel is present. But this occurrence 
may be induced by causes entirely independent of the uric acid diathesis, 
a purely local inflammation of the urinary apparatus sufficing for its pro- 
duction (Brodie, Rayer). 2 More than once I have had an opportunity to 
discover a complete absence of uric acid in the serum of the blood of non- 
gouty individuals who habitually passed uric concretions of larger or 
smaller size during the act of micturition. 

Still, I do not mean to absolutely deny a correlation between these two 
orders of occurrences. Far from it— for it is established that gravel, in 
certain patients, arises from the presence of an excess of uric acid in the 
blood. Dr. Ball communicated a case to me where a man, sixty -four years 
of age, frequently passed small uric calculi after a violent attack of renal 
colic. A blister having been applied to the epigastric region, it was found 
that the serous fluid obtained in this manner contained a considerable 
quantity of uric acid. This patient, however, had never had any of the 
symptoms of articular gout, and had no albuminuria. This case must un- 
doubtedly be associated with those where gravel is seen to precede the 
occurrence of gout, and thereafter to alternate with this disease. 

Indeed, we can make three classes in this connection. Sometimes gravel 
precedes gout ; this is most frequently the case. Sometimes it follows it ; 
this more rarely occurs. And again, rarest of all, these two conditions 
coincide. In five hundred cases of gout, Scudamore met with only five 
who had calculi : and Brodie claims never to have seen gravel in a gouty 
patient who had tophaceous concretions or chalk-stones. 

The symptoms resulting from gravel commingle with those of gout. 
There may be emission of fine gravel with the urine, and a transient albu- 
minuria ; there ma}' be renal gravel, which Rayer describes under the name 
of gouty nephritis ; but we know there exists another form of gouty ne- 
phritis characterized by deposits of urate of soda in the parenchyma of the 
kidney (the English authors' gouty kidney). Finally, ischuria maybe pres- 
ent hi the gouty, and renal colics, gouty pyelitis, and irritability of the 
bladder may occur. All these phenomena which may coexist with gravel, 
are not necessarily the results of it, but, as we have previously seen, they 
all may simulate that condition. 

C. — Gout, scrofula, and phthisis. — Does there exist, then, a real connec- 
tion between gout, scrofula, and phthisis ? We are little disposed to affirm 
this absolutely, but it is true that scrofula is frequent in those subject to 
nodular rheumatism. We may then question whether we ought not to as- 
sign to this latter affection what was attributed to gout. But Prout, who 
has carefully studied this point, admits that scrofula and gout are frequently 
associated, and that the children of gouty parents are predisposed to phthi- 

1 Parkes: On Urine, p. 218. London, 1860. Ranke : Ausscheidung der Harnsaure. 
Miinchen, 1858. 

'-' Lemons sur les Maladies des Organes Urinaires. Transl. by Patron, pp. 251, 278. 
Paris, 1745. Maladies des Reins. Vol. I., pp. 94, 197, 198. Paris, 1839. 



80 CLINICAL LECTURES OX 

sis. 1 This latter disease, quite rare in acute articular rheumatism (Wun- 
derlich, Hamernjk *), is frequent in patients who have chronic articular rheu- 
matism, while in gout, on the other hand, it rarely occurs, although diabetes, 
whose close relationship to gout we have just described, is. as it were, an 
ever open gate for the entrance of phthisis. Garrod, however, saw phthisis 
develop and run a rapid course in a young man who had tophaceous con- 
cretions around several joints ; but this ought to be regarded as an excep- 
tional case. 3 

D. — Gout and cancer. — Does gout exclude cancerous affections? Or, on 
the other hand, does it favor their development ? 

My former teacher and predecessor in the v ,. be- 

lieved in the existence of a close connection between these two diatheses. 

For myself, I can affirm as a certainty, that in nodular rhi 
cer and cancroid growths are not exceptions] J 

had an opportunity of meeting examples of it in esses of 
gout, but Bayer describes the existence of both t 

the same individual, at least in the same fainik ise published some 

years ago in an English journal * proves thai these 
united in the same person. It w 
cer- cells in the lungs and liver, occurring in 
years old, who had largi 
acteristic infarctions of urate of soda in tl 
sufficient to demonstrate that at 1< uA w i 
tween gout and cancer. 

E. — Gout and rheumatim 
rheumatism and gout have led many obstnrvi 
proclaim the identity of these two disessi B. We shall 
to give an opinion upon this point when we shall h 
and hence we reserve this discussion for anon 



1 Prout: Loc. cit, p, 408. 

5 Wunderlich : Patholo^. und Therapie. Bd. iv.. p 

3 Garrod: On Gout, p. < Biidd : Lancet, p 492. 1851 



THE DISEASES OF OLD AGE. 81 



LECTUKE IX. 

ETIOLOGY OF GOUT. 

Summary. — Study of the Conditions which Govern the Development of Gout — Suita- 
ble Method to follow in Making this Kind of Investigation — Inconvenience of the 
Premature Intervention of Chemical and Physiological Theories — Necessity of 
Separating Acquired Facts from the Hypotheses which have been advanced as Ap- 
plicable to them — Historical Pathology of Gout — Antiquity of this Disease — Wri- 
ters who have Described its Existence — Diminution of Gout in Modern Times — 
Permanence of its Characteristics — Modifications arising from our Hygienic 
Habits and their Probable Consequences — Medical Geography of Gout — Its Resi- 
dence especially in England and in London — Met with, however, to a less Ex- 
tent in some other Countries — Almost wholly Disappears in Hot Climes — Analyti- 
cal Study of the Causes of Gout — Causes in the Individual : Spontaneity— Heredity 
— Sex — Age — Temperament, Constitution — Hygienic Causes : Climate — Over- 
eating, Want of Exercise — Intellectual Work — Venereal Excesses — Fermented 
Liquors: Ale, Porter, Wine, and Cider — Exciting Causes. 
.leuilLv. — English Beers. 

Gentlemen : — Hitherto we have studied gout in relation to the lesions 
which accompany the symptoms which characterize, and the affinities which 
bind it to other discuses. There now remains for us to seek the conditions 
presiding over its development ; we shall therefore, in a few words, point 
out the method we purpose to follow in the course of our investigations. 

We shall first begin with the empirical study of facts furnished us 
by direct observation, outside of all theoretical prejudices. Then we shall 
endeavor to interpret these data from the standpoint of modern physi- 
ology ; in other words, we shall try to follow, in their successive develop- 
ment, the modifications which the organism may undergo through the 
influence of those causes from which experience teaches us gout arises. 
Afterward it will be necessary to ask ourselves how the changes thus oc- 
curring in the economy can induce the various phenomena that make up 
the clinical history of this disease ; in a word,- we shall endeavor to obtain 
an idea of the pathological physiology of gout. And this is the crowning work 
in all nosological study. 

It must be acknowledged, however, that the rigorous and systematic 
separation of the two standpoints we have just described is far more requi- 
site in the question we are discussing ; for it is here, especially, that the 
premature and rash intervention of chemical and physiological theories to 
account for the morbid phenomena, may tend to bring this kind of study 
into unmerited discredit. 

He who shall succeed in harmonizing the pathology of the ancients and 
the physiology of the moderns, will surely, says Boerhaave, deserve the 
highest praise. 1 But modern physiology in Boerhaave's time scarcely cor- 

1 Nee in medicura plus laudis redundare posset, quam ex eo labore, quo veterura 
pathologiam redigeret ad neotericoruni pkysiollfiam. — Boerhaave: Med. Stud. Medic. 
Pars, ix., Pathologia, p. ol'o. 
6 



82 CLI1S1CAL LECTURES OX 

responds to the science as we understand it to-day ; and so, in the coming 
centuries, may contemporaneous physiology likewise become as obsolete in 
its turn. Hence, we must use the utmost reserve, and advance along thi3 
path only after infinite precautions ; for what our predecessors lacked was 
not an appreciation of the important role which physiology plays in medi- 
cal studies, but broader and more exact notions concerning those diffi- 
cult problems they sometimes attempted to solve without having first 
measured their extent. 

Indeed, it must be acknowledged that the history of the products of 
disassimilation still remains obscure, notwithstanding the progress we have 
made in the study of the nutritive functions ; and uric acid, especially, is 
no exception to this rule. "We know very little concerning the conditions 
which preside over its regular formation, and the pathological circum- 
stances that may modify it. Thus, at the very commencement it is easy 
to foresee that the pathogenesis of the uric acid diathesis is still in a rudi- 
mentary condition, and that, consequently, at the present time it is iinpossi- 
sible for a complete theory of gout to be drawn up ; at the utmost we are 
only permitted to place a landmark here and there, which may, perhaps, 
serve to direct the investigations of those who come after us. 

We shall begin this analysis with a rapid glance over the history and the 
geography of gout, for, since we are concerned here with a constitutional 
disease, and one essentially arising from the general state of the individual, 
it is absolutely necessary to study in order that we may obtain a linn grasp 
on its characteristics, the climatic and social conditions which, collectively, 
seem to predispose the human species to this malady. To regard ad. 
in this light is to construct its etiology on a grand scale. 



I. — Historical Pathology of Gout. 

To recount the vicissitudes which diseases have experienced in the course 
of centuries, and to search in history for the causes of these changes— this 
is the chief aim of historical pathology ; and besides, h. ns of this 

kind enable us not only to appreciate the pathogenic influence of external 
causes, but also the results of the inherent conditions of man himfi 

But, in order that it may be possible to apply this process to the study 
of a disease, the attention of our predecessors must have long since been 
called thereto ; and it is only in these cases that one may hope to g 
an ample harvest from historical documents. Now. similar conditio: 
rarely realized, except in the case of epidemic d which used t 

duce such terrible ravages — and of certain chronic affections which, in all 
times, have attracted the notice of investigators. A few examples will en- 
able you to readily grasp my idea. The plague, so formidable in 
times, appeared, for the last time in France, at the beginning of th« 
vious century (1721); it is tending, also, to become extinct in ti 
countries which have always been its principal centres. One may. then, 
with reason* demand what the conditions were which, in past tin:< - 
its development, and which to-day seem to have ci 
was still extant in Martigues at the end of the last century, but sine, 
epoch it has disappeared from French soil ; it is becoming r 
in Europe, tending to take refuge in Norway, as the gout does ii 
land. We can readily undersiafl how much attraction i 
phic physician the history of an almost extinct disease may hai 



THE DISEASES OF OLD AGE. 83 

has played so great a part and occupied such a prominent position in the 
minds of legislators of every century. J 

Among the diseases whose historical study offers a truly scientific in- 
terest, gout clearly stands in the first rank ; indeed, it is certain that thi3 
disease used to prevail in a somewhat epidemic manner among the more 
favored classes of society. To-day it is seen gradually to become extinct, 
although it has not undergone any change in its symptomatic development 
since the most remote epochs, inasmuch as we find it completely described 
in the works of the ancients. 

We shall now give you a succinct statement of the principal data fur- 
nished us by history for the solving of this question. 



Antiquity of Gout. 

There is no doubt but that gout has been known in Europe since the 
days of remotest antiquity ; the writings of Hippocrates are proof of this. 
But it is in the reign of the first Caesars that it seems to have reached its 
culmination ; and in this connection we possess unexampled accounts that 
leave nothing to be desired. The writings of physicians, the works of his- 
torians, the satires of poets — all are filled with allusions to this malady. 

In the first century of the Christian era, Aretaeus and Celsus on the one 
hand, and Ovid and Seneca on the other, have given ample information 
concerning the pathological condition of the Roman people in this regard. 
In the second century, Galen (130 a.d.) and the interesting dialogues of 
Lucian of Samosata 2 furnish us with details valuable both from a hygienic 
and a medical standpoint. In the third century an edict of Diocletian ex- 
empts gouty subjects from public services when they are attacked with 
articular deformities great enough to interfere with the exercise of the 
ordinary functions of life, a circumstance which seems to prove both the 
extreme frequency of gout at that period, and the immutability of the chief 
symptomatic characteristics of this disease. 

From the third to the sixth century things seem to have remained un- 
altered, if we may judge from the writings of Oribasius (326-403 a.d.), 
Alexander of Tralles (525-605 a.d), Aetius, Paulus of iEgina (660 a.d.) and 
many other physicians. In the middle ages the Arabians, continuing the 
medical traditions of antiquity, inform us that gout has lost scarcely any 
ground since that epoch 3 ; and the authors of the Lower Empire (Byzan- 
tine), Actuarius, Demetrius Pepagomnenus, etc, carry us up to the thirteenth 
century. Modern times being reached, we find ourselves confronted by 

1 The stringent measures which inflicted upon the leper an absolute isolation from 
all society were maintained with unrelaxed severity during the middle ages. They 
may have contributed to the extinction of leprosy. Certain pathologists prefer to in- 
voke, in these cases, a morbid spontaneity, and we willingly accept the term, provided 
it be thoroughly understood that it prejudges in nowise the real gist of the question, 
and only serves to express a gap in our knowledge. 

2 Tragodopodogra; Okupous the Fleet-footed. The latter poem, according to some 
critics, should not be attributed to Lucian. Okupous, one of Homer's names for 
Achdles.— L. H. H. 

3 It must not be forgotten, however, that the information offered by the authors of 
that period is not always worthy of absolute trust. Too often they copy from one 
another, without thinking of collecting personal observations. The Arabians, espe- 
cially, have borrowed largely from Greek medical literature ; and as gout is fre- 
quently discovered in the works of the ancients, they certainly appropriated a consid- 
erable part of their labors. 



84 CLINICAL LECTURES ON 

innumerable evidences that leave no doubt as to the general diffusion of 
gout over Europe. 

And thus, gentlemen, you see an uninterrupted chain of historical 
proofs testifying that for more than twenty centuries this disease has held 
sway in the countries we now inhabit. But to-day we need only glance 
around us in order to convince ourselves that gout is becoming rarer and 
rarer ; and here it is proper to enter into a few details. 



DrviiNunoN of Gout in Modern Times. 

This retrograde movement of gout seems especially to have manifested 
itself since the beginning of the present century. Documents collected by 
Corradi ' inform us that even in England this disease is diminishing in fre- 
quency, according to Owen and Fuller ; that it 1ms markedly declined in 
Holland, according to Coley ; and also in Switzerland, according to Pro- 
fessor Lebert. It has almost disappeared from those localities where it 
used to prevail, for in our time it is scarcely ever met with in Rome or 
Constantinople. In this respect it is evident that the state of afiair- 
undergone considerable change. And this, undoubtedly, is the reason 
the works which have appeared upon this subject within the 
are so few in number ; for, save in England, materials for new investiga- 
tions in gout are very rarely obtained from observation. 

In spite of its decadence, however, this d baa undergone no 

change in its symptomatic developments, as you will soon see. 



Permanence of the Characteristics of Gout. 

We have only to compare the descriptions bequeathed to us by antiquity 
with those found in modern works, to convince our . clini- 

cal standpoint, gout has always remained true to its primitive type. Oku- 
pous the fleet-footed 12 completely n in this respect) the cases 

observed by Van Swieten, sixteen hundred years Liter. 

Concerning the etiology, we are always confronted by the same con- 
ditions. Suetonius called gout mfifbua domxnorum, and B m has 
expressed the same idea in slightly different terms As for the mi! 
exercised upon the development of this .s has 
always figured in the universally accepted class of traditie: 

And finally, let us add that the Greek and Roman pi who 

described the characteristics of gout so concisely, barely mentioned the 
existence of articular rheumatism ; so that many authors consider it a new 
disease, or at least as one almost unknown in ancr 1 This is the 

opinion of Sydenham, reiterated later on by Hecker and Leupoldt.' 

Farther on we shall have an opportunity to prove to you. by nnei 
tionable evidence, that there is much exaggeration in this way of looking 
at it, and that rheumatism most certainly existed among tbl 
of antiquity ; but in this case there was Barely quite trust, 

and one which suffices, at all events, to show that the general physiognomy 
of gout has never varied. 



} Delia odieraa diminuzione della podojra. etc.. del Di so Corradi. 

Bologna, I860. 

> Hecker: Rede uber die anfeinandei Folge der Dyakraaten. - 
einzeit, 1837. Leupoldt: Geschichte der Mcdiciu.. p 



THE DISEASES OF OLD AGE. 85 

What deductions may we draw from the facts we have just set forth ? 
Shall we admit, with Corradi, that the decadence of gout results from mod- 
eration in our customs and from a better alimentary hygiene ? There cer- 
tainly has been a great change in our habits in this respect. The suppers 
of Lucullus have disappeared for many a century ; we no longer possess the 
heroic appetites of the doughty knights of the middle ages ; nor is it the 
fashion to-day to gather, as at the feasts of the Burgraves, 

" Autour d'un boeuf entier, servi sur un plat d'or." l 

"We are accustomed to a less abundant diet, to one consisting less ex- 
clusively of animal food, and our repasts are not so prolonged ; besides, the 
abuse of fermented drinks has considerably diminished, even in England, 
where the customs of the last century left much to be desired in this 
respect 

IL — Medical Geography of Gout. 

Medical geography is, equally with historical pathology, one of the 
most fruitful means of investigation in etiological research. It enables 
us to become acquainted with the different regions of the globe in which 
certain diseases prevail, and thus allows upon the grandest scale, a study 
of the cosmical, tellurial, and even anthropological conditions that may 
favor or hinder their development 

Concerning gout in particular, geography teaches us that to-day it only 
exists upon one spot of our globe in the condition of a generally diffused 
malady : this, of course, is in England. Here, however, England proper 
is meant, for neither Ireland nor Scotland is in the same position, in this 
regard, as the southern portion of the United Kingdom. Besides, it is 
in London especially that the predominance of gout is shown : in that 
city it prevails, not only among the best classes of society, but even 
among the body of the people and working-classes least favored in respect 
to the necessaries of life. We shall endeavor, farther on, to explain the 
reason of this singular choice of habitation. We will merely say, for the 
time being, that gout exists in other parts of the globe, though in a very 
much less degree. It is met with in some portions of France, especially 
Lorraine and Normandy, the provinces which have in all times been noted 
for their good fare. It is likewise present in Germany, and in countries 
where beer is the ordinary beverage of the population. 

It is certain, moreover, that this disease is only prevalent in the tem- 
perate regions of the earth. Near the equator and in the tropics, gout is 
hardly known ; in India it sometimes attacks Englishmen, though less fre- 
quently than in their native country, while it spares the indigenous popu- 
lation. In Egypt it only attacks the Europeans and those comfortably 
conditioned Turks who set at naught the precepts of the Koran ; but 
the fellahs seem to enjoy absolute immunity. 

Finally, in Brazil they hardly know what gout is, although the diet of 
the inhabitants is very highly animal (Dundas). I have taken most of these 
details from Dr. Hirsch, of Berlin, who has published an excellent work 
upon this subject. 2 

Climate has a most obvious influence here : it is not a question of race, 
for the negroes in the English army, when placed under the same conditions 
j» — 

1 Around a tvhole ox, served up on a golden dish. 

2 Handbuch der historisch-geogr. Pathologie. Erlangen, 1859. 



86 CLINICAL LECTUEES ON 

as the whites, are, like the latter, liable to contract gout ; this seems to be 
proved by some observations reported by Quarrier. 1 

Articular rheumatism behaves in a very different fashion in the above 
respect : it appears to exist in all climates, being often met with in India in 
the acute, as well as the chronic form : indeed, to use an expression of 
Mtihry's, rheumatism is an ubiquitous disease. 2 Here is a striking differ- 
ence between these two analogous diseases ; and one which it is important 
to point out. 

We have only sketched the most salient points of the pathological his- 
torj and medical geography of gout. Now, however, we must abandon 
this " straightforward " method of study, descending from the very general 
standpoint we have taken in order to engage in the minute analysis of those 
particular circumstances which may give rise to this disease. In the 
course of this study we shall have an opportunity to point out facts that are 
still but little known in France, and which, in every respect, merit your 
attention. 



ANALYTICAL STUDY OF THE CAUSES OF GOUT. 

I. — Causes whose Sevt is in the Individual, 

A. — Spontaneity. — It is a point beyond dispute that gout can develop 
spontaneously; facts adduced by all authors prove it, and I have m 
met with such cases. There reside, then, in the very constitution of some 
individuals, conditions which are favorable to the development of gout, and 
external circumstances do nothing but bring out the disease. In this there 
is nothing that should astonish you : for an excessive production, or a 
faulty elimination of uric acid seems to be the fundamental condition f 
gouty diathesis. We find uric acid a normal ingredient in the circulatory 
fluid, and for ever so slight an increase in this quantity, the whole train of 
pathological changes may be displayed. 

B. — Heredity. — The definition of gout as expressed by modern writers 
always entails the idea of heredity. Physicians who collect observations 
from hospitals have already established the truth concerning tins point, 
namely, the frequency of hereditary transmission; and in private practice 
this influence of heredity is recognized i. I shall submit a few sta- 

tistics to you, which may impart an approximate idea of the importance of 
this condition. 

Scudamore met with heredity in 309 out of 523 cases, or in a little over 
fifty-nine per cent. 

Patissier {reports) 34 times in 80 cases, or in more than forty-two 
cent. 

And Garrod in 50 out of 100 cases, or in one-half. 

Hereditary gout often develops quite early, and before the time 
usually happens from other causes. Now. ordinarily, gout of a spontane- 
ous origin makes itself manifest between the thirtieth' and the thirty-fifth 
years of life ; but hereditary gout does not wait so long a tin* 
ing itself. It often makes its appearance at one definite age in each l 
ber of the same family. Garrod records a case where, in one of the . 

J Edinburgh Med. and Surof. Jonm Vol. ii.. p. 451 
-Klimatoiogisohe Vutersuchuugeu. p. 818, I 



THE DISEASES OF OLD AGE. 87 

English families, the eldest son was attacked with gout the day he received 
the ancestral heritage; and, moreover, this succession was perpetuated dur- 
ing four centuries. 

C. — Sex. — The influence of sex upon the production of gout is not less 
evident than that of heredity. In this respect women enjoy a comparative 
immunity impossible to deny. Of the eighty cases collected by Patissier, 
there were only two belonging to the female sex. It is at the time of the 
menopause that these phenomena occur — a fact observed by Hippocrates. 

Now, as we shall soon see, chronic rheumatism essentially differs from 
gout in this regard. There are, however, exceptions to the rule, and 
women are sometimes seen to become subjects of gout quite early in life ; 
but here we will almost always recognize the influence of heredity. 

Finally, let us add that it is the asthenic form of the disease, especially, 
that prevails in the female sex. 

D. — Age. — From the thirtieth to the thirty-fifth year of life is, accord- 
ing to Scudamore, the classical age for gout. It is very rarely seen before 
the twentieth, or after the sixtieth year. Garrod, however, met with it 
once in a nine-year old patient, and once in a young man under seventeen 
years of age. He also reports a few cases where this disease was developed 
in men from sixty to seventy years old. 

Kheumatism, on the other hand, appears earlier, and is generally ob- 
served before the age of thirty-five. 

E. — Temperament, constitution. — It has frequently been attempted to 
collect together characteristics of a special constitution predisposing to 
gout ; but the study of facts tells us that it respects no temperament, and 
may develop in the feeble as well as in the most vigorous constitutions. 
The type of the disease, however, is modified by the general state of the 
organism ; the sthenic form occurs especially in the sanguine and plethoric, 
while the asthenic variety is met with in women and those of a nervous 
temperament. 

H. — Let us forego, now, the further study of the causes residing in the 
individual, to consider those resulting from his surrounding circumstances, 
first discussing hygiene, and especially alimentation, since in this way we 
shall obtain valuable data for the solution of the problem we are endeavor- 
ing to elucidate. 

A. — Climate. — Medical geography has already demonstrated that gout 
belongs solely to the temperate regions of the earth, to all appearances 
avoiding the tropics. Unknown in Brazil, Africa, and the equatorial re- 
gions, it sometimes, however, attacks those Europeans who continue the 
habits of a cold climate while residing in a hot country ; and this is why 
the English in East India are often liable to be attacked with it. 

B. — Excess in eating and want of exercise — It has always been recognized 
that too nourishing a diet and too idle a life — two causes frequently acting 
in concert — directly predispose to gouty manifestations ; and this is un- 
doubtedly the reason why it prevails among the higher classes, and is less 
frequently met with among the masses. This is familiarly expressed by 
saying that gout proceeds from an excess of receipts over expenses. We 
shall soon see that facts do not sustain such a simple interpretation ae the 
above ; it is, at least, certain that a diet consisting of too much animal food 
favors the development of this malady, and that large eaters are frequently 
among the number of its subjects. 

C. — Influence of the nervous system. — We may no longer 'deny the influ- 
ence exercised by cerebral causes ; and intellectual labor, moral emotion, 



S8 CLINICAL LECTURES ON - 

and intensity of thought have always occupied an important position in the 
etiology of gout. This justified the witty mot with which Sydenham con- 
soled himself for being a sufferer from gout : " Livites interemit ptures quam 
pauper es, plures sapientes quam fatuos," are the words he uses in speaking 
of this disease. 1 It is indisputable that the most distinguished political 
characters in England, at least, were martyrs to this affection ; we may cite, 
among others, the case of the two Pitts. The first of these two great min- 
isters — the Earl of Chatham — was known to be no worshipper of Bacchus ; 
while the same cannot be as truly said of his son, William Pitt, who never 
spoke in the House of Commons without having first fired his eloquence 
with copious libations. 

D. — Venereal excesses. — Abuse of venery may clearly act in an unfavor- 
able manner upon gout, on account of the perturbation of the nervous 
system which results from it. But we have recourse here to a much sim- 
pler explanation : it is well known that excesses of this sort are closely 
connected with the carouses succeeding feasts, and it is to the co-operation 
of the latter occurrence, perhaps, that we must here assign the principal 
role. 

Two other causes remain to demand our attention ; I refer to the influ- 
ence of fermented drinks and of saturnine poisoning. 

The action of fermented liquors is so evident, that Garrod has well 
said: "Man, deprived of these beverages, would never have known the 
gout." 

The province of lead-poisoning is, in this respect, much more limited ; 
but, from a standpoint of pathogenesis, this aspect of the question is of the 
deepest interest. 

We shall consider, in order, these two classes of phenomena. 

E. — Fermented liquors. — From our point of view, we must make a 
radical distinction between spirituous liquors (rum, brandy, whisker 
etc.) — liquors which contain from forty to seventy parts of alcohol in one 
hundred — and the simple fermented beverages (wine, beer, cider, etc.), 
whose alcoholic strength varies from four to twenty per cent. At the first 
glance it looks as though the more a liquor is charged with alcohol, the 
more it predisposes to gout ; but such is not the fact, and you will I 
tonished to learn that the use — even the abuse— of distilled liquor does 
not seem to exercise the slightest influence in this respect. In 
is hardly ever met with among people who drink brandy, h 
where alcoholismus is so frequent — according to Magnus Huss — this d 
is out of the question ; and it is the same in Denmark, Russia, and Poland. 
In Scotland and Ireland, gout is rare among the lower classes. In Kdin- 
burgh, with a large hospital practice, Bennett 3 and Christison met with 
barely more than one or two cases of it. Xow, in these countries, the only 
alcoholic liquor which the people drink is whiskey. 

In London, on the other hand, gout is a very common disease among 
the working classes, and is frequently met with in the hospitals. Now, the 
only fundamental difference that can possibly be established, in tl 
spect, between the northern and the central portions of the United King- 
dom, is the enormous consumption of strong beer (ale, stout, and porter) 
by the laborers who live in the metropolis. 3 

1 It kills the rich oftener than the poor, the wise man oftener than the fool. 
Clinical Lectures, etc., by J. Hughes Bennett Second edition, p. Dili. Edin- 
burgh, 185S.— L. H. H. 

3 See Appendix, inserted at the close of this lecture. 



TIIE DISEASES OF OLD AGE. 89 

This truly remarkable influence of these beverages lias been recognized 
by all English writers on the subject, commencing with Scudamore. He 
tells us that " gout is much more frequent in London, among the masses, 
since the use of porter has become habitual." The testimony of Watson, 
Budd, and Todd also corroborates this assertion : " Most of those who are 
given to the use of beer, especially porter, sooner or later suffer from gout," 
says the last-named of these three authors. 

An example borrowed from Budd * will illustrate the influence which 
this kind of liquor exercises. There is, in London, a body of laborers who 
work at the raising of ballast from the bottom of the Thames. This is 
done during low tide, and consequently, the working hours fall sometimes 
during the day-time, and at other times at night. The workmen, who are 
exposed to all sorts of inclemencies, are also obliged to expend great mus- 
cular effort ; and, in order to obtain the best return (please to notice here 
the practical nature of the English), a large allowance of porter is given to 
these men. Each one drinks two or three gallons a day ; and, apart from 
this enormous consumption of fluid, their diet is that of the very lowest 
classes in London. 

Now, gout is an exceptionally frequent disease among these poor men, 
who share this sorry privilege with the peers of the realm ; and although 
their numbers are but very few, many of them are each year admitted as 
gouty subjects in the Seamen's Hospital. And yet, these are generally 
unfortunate Irish peasants, in whom an hereditary vice of constitution 
could not be advanced as a cause. 

Garrod, on his side, attained the same results. He states that the em- 
ployes of large breweries are frequently attacked with the gout, and yet 
nothing can be found in their antecedents to explain this morbid predis- 
position, except it be the abuse of ale, and porter especially. 

These two beverages, however, are not remarkable for their richness in 
alcohol ; according to Mulder, Scotch ale contains eight per cent, of alcohol, 
and porter five per cent. a This proportion is smaller than that in our French 
wines, and does not exceed that of the German beers, which seldom pro- 
duce such effects, in spite of the large amounts drunk in the breweries. 

It is evident, consequently, that d priori reasoning cannot be applied to 
the question we are discussing, and that the influence of fermented drinks 
upon gout is far from corresponding to their percentage of alcohol. Cir- 
cumstances of a different kind, which have escaped us to this day, probably 
interpose themselves at this point ; and for every kind of liquor we must 
have recourse to the data of direct experimentation. 

We shall now consider the action of wine. The first rank must here be 
conferred upon the spirituous wines (Port, Sherry, Madeira, Marsala), which 
are so extensively used in England, in all classes of society. These contain 
a considerable quantity of alcohol, varying from seventeen to twenty per 
cent. 

The lighter wines (Ehine, Moselle, Bordeaux, Champagne) are far 
from exercising the same influence as the former class. 

But we cannot say the same of Burgundy, which nevertheless, contains 
scarcely more alcohol than the preceding. 

" Red Hermitage and Burgundy, the latter especially," Scudamore says, 
" contain gout in every glass." 

1 Tweedie : Library of Medicine. Vol. v., Art. Gout. Also in Bennett's (J. Hughes) 
Clinical Lectures, etc., p. 992. Edinburgh, 1868.— L. H. H. 

2 Mulder : De la Biere. Trad. Delondre, p. 327. Paris, 1861. 



90 CLINICAL LECTUPwES ON 

Even cider, that beverage seemingly so free from danger, also appears 
to favor the development of gout. According to Garrod, it is soft | 
cider, and that having undergone only partial fermentation, which possesses 
this unpleasant property. 

I think that, as the influence which certain beverages exercise in this 
regard has been sufficiently well proved, we may now safely pass to the 
consideration of another subject. 

B. — Lead-poisoning. — Garrod states that out of fifty-one gouty patients 
who were in his service at the hospital, no less than sixteen were painters 
or plumbers by trade ; and subsequent researches only confirm this strange 
result. Thus, saturnine impregnation has been ranked among the predis- 
posing causes of gout. 

This coincidence once pointed out, documents in its support flowed in 
from all quarters. Among the authors anterior to Garrod, Musgrave may 
be cited as one who noticed gout following lead-colic, Falconer as another 
making the same observation, and Parry, who, in his collection of cases, 
has shown that gout is frequent in those attacked with lead-paralysis. 
Finally, Todd reports several cases of gout occurring under analogous cir- 
cumstances. 1 

Since the publication of Garrod's work, several English authors have 
described cases of this kind ; we may especially cite Burrows and Begbie." 
But in England we must take into account those alimental c have 

just enumerated. In France, where lead-colic is so common, low does it 
happen that gout is so rare among the great mass of the population ? 

Well, in cases of saturnismus there are a few patients with the gout in 
whom lead-poisoning is the only cause that can possibly be adduced. "We 
have ourselves had an opportunity to observe a very remarkable ease of this 
kind, and Dr. Bucquoy has just reported an almost identical case in Charity 
Hospital. 

It now remains to determine the cause of this singular coincidence. 
Garrod affirms that an impregnation of the system with had leads to an 
accumulation of uric acid in the blood, especially in advanced eases where 
there is paralysis ; this fact has been established in non-gouty cas 
saturnismus, which seem not to have been albuminurious ; for their urine 
had been examined, and it had been determined that the proportion of uric 
acid was sensibly diminished ; but in these analyses there was no qui 
of the presence of albumen. Garrod asks himself whether, in tin- 
there was an over-production of uric acid, or a failure in excretion of this 
product. He leans toward the latter hypothesis, and this is * 
ment on which he bases his view : after baring for several days examined 
the urine of a certain number of patients suffering from various disc - 
order to establish the normal proportion of uric aeid. he commenced to 
employ acetate of lead medicinally with them, and he found that the ex- 
cretion of uric acid diminished. 

It is then by paralyzing the action of the kidney, at least so far as con- 
cerns the elimination of uric acid, that lead favors gouty mar. 
but can the disease arise from the influence of this cause* alone ? In a few 



1 G-. Musgrave: De arthritide symptomatica, c. x . art. 5, v 
C. H. Parry: Vol. i., p. 243. Loudon, 182o. Todd: Practical Remark^ 
p. 44 London, 1843. 

2 W. Falconer: Brit. Med. Jour., p. 464. 1801. P,egbie : Edinburgh Med. Jour., 
p. 128. August, 1802. Charcot: Gazette Hebdom., p. 433. It 



THE DISEASES OF OLD AGE. 91 

exceptional cases perhaps it can ; but if there are any adjuvant causes, the 
effects of lead will be exhibited last of all. 

LTI. — Exciting causes. — Incapable themselves of producing gout, still 
the conditions we are about to enumerate possess great potency in bring- 
ing about the development of an attack. 

A. — Alcoholic beverages. — The ingestion of but a small quantity of cer- 
tain wines (champagne and port, for example), in the case of gouty patients, 
is enough to induce at one time a violent attack of gout, and at another 
simply a swelling of the great toe. Hence, Garrod has well said : "In what- 
ever individual a few glasses of wine are always sufficient to rapidly and 
invariably provoke an inflammation in a joint, that inflammation is certainly 
of a gouty character." 

B. — Attacks of indigestion, and gastric derangements act in a similar 
manner. 

C. — Wet cold and suppression of the perspiration are in the same cat- 
egory. 

D. — Excessive intellectual labor, to which we have already alluded as a 
determining cause of gout, is included also in this enumeration. 

E. — Traumatic causes, operations, fractures, etc., act in like manner, 
and I have seen a wound simultaneously induce an attack of trismus and 
one of gout. 

F. — Debilitating causes — hemorrhage, bloodletting, and grave diseases — 
also exercise their influence upon the production of an attack. It is all 
the more interesting to notice this point, since people are fond of painting 
gout as a disease of plethoric individuals ; but Todd has shown that it 
readily attacks debilitated subjects. 1 

"We shall devote our next lecture to the theory of gout. 

1 Recently I had under my charge a former officer in the Confederate Army, who, 
during the rebellion in the United States, was made prisoner by the Union troops. 
Confined in a damp and unhealthy prison, and having a very insufficient diet, he be- 
came a subject of gout ; he remains so till this day. and yet he has no hereditary ante- 
cedents that could predispose him to gout, and previous to that time he never had the 
least indication of the disease. 



92 CLINICAL LECTURES ON 



APPENDIX TO LECTCHE IX. 

English Beers. 

The question of the influence exercised by ale and porter upon the de- 
velopment of gout is one that frequently recurs in these lectures, and it 
seems to me to be necessary to present, in this connection, some descrip- 
tion of the processes employed in making these beverages, and the chief 
properties that characterize them ; so I requested Dr. Ball to prepare for 
me a short account bearing on these points, which I here present to the 
reader. The information therein is all the more useful, since it can be 
found in no medical work published up to this time. 



It is beyond dispute that, from the remotest antiquity, people who 
were not acquainted with the use of wine discovered the means of utilizing 
germinated barley (malt) in order to procure alcoholic bev- 
before they left their forests the Germanic tribes possessed this art. and 
thus we are not astonished to find beer naturalized in England from the 
time of the Anglo-Saxon conquest. The laws of Ina. King at \ 
country of the Western Saxons), which were promulgated in 72s, already 
make mention of ale and alehouses ; and from that epoch beer has never 
ceased to be the natural beverage of the English. 

But during the course of these many centimes public taste has varied 
more than once, and the brewers have been obliged to follow the fashion, 
except, indeed, when they have forestalled it. In the middle ages hops 
were not employed in beer-making, the beverage seeming to have fa 
insipid and sweetish taste ; and they endeavored to correct this fault by 
the addition of infusions of bitter and aromatic herbs. It was in 1524 that 
the Flemings caused hops to be introduced into English brewing ; but this 
practice was not legally authorized until 1552. The name ale was then 
given to the sweeter beverages prepared from malt {germinated grm n), while 
the term beer was reserved for those impregnated with the bitten- 
hops. In the seventeenth century, however, every vestige of this dis 
tion was swept away, and hops were universally employed in the English 
breweries. 

The origin of porter is of much more recent date. It was in 1730. ac- 
cording to Malone, that it commenced to be used for the first time. About 



Herodotus and Diodorus (of Sicily) tell us that the Egyptians knew how to make 
beer. Phny and Tacitus testify the same as regards the German*. "Potui humor 
ex hordeo aut f rumento in quamdam similitudineiu vini eorruptus." — Ta, 
moribus, ac populis Germ., cap. xxiii. 



THE DISEASES OF OLD AGE. 93 

that time the workingmen of London were in the habit of drinking, in the ale- 
houses, a mixture of beer, ale, and small beer, which they called three threads, 
because for every pint he drew for a customer, the inn-keeper was obliged 
to go to three different casks. In order to avoid this inconvenience, the 
brewer Harwood thought he would make a beverage that would combine 
the flavor of these three ; he succeeded admirably, and the success attained 
by the new drink among the lower classes of the metropolis was such 
that the name porter ' was given it, a name which it has retained till this 
day. 

To please the popular taste, they formerly gave this porter a very deep 
color, by prolonged torrefection of the grain. But it was soon perceived 
that, by doing this, they destroyed the greater portion of the saccharine 
matter contained in the malt, and that the richness of the liquor in regard 
to fermentable principles was diminished thereby. Recourse was then had 
to a number of artificial processes for coloring porter, which were prohib- 
ited in 1816 by an act of parliament ; and the only ingredients which, to- 
day, serve for the manufacture of beer, are water, malt, and hops. 

It w T as then discovered, however, that complete torrefaction of malt, 
though destroying the sugar it contained, gave rise to a very soluble color- 
ing matter : and since then this substance, which came within the terms 
of the law of 1816, was largely enrployed in making porter. 

To-day this beverage is a mixture of several kinds of beer, kept a long 
time after being commingled, so as to push fermentation to its utmost lim- 
its and convert all the sugar into alcohol. But, since the malt is exceed- 
ingly torrefied at the commencement, it contains but little glucose at the 
very moment when the working begins, and consequently can never be as 
rich in alcohol as the other varieties of beer. Its essential characteristic, 
however, is a tendency to acetic fermentation, for, all the sugar being de- 
stroyed, one more step sufiices to convert the alcohol into vinegar. From 
a theoretical standpoint, this change ought never to take place ; but prac- 
tically the porter delivered for use is frequently acid, a fact of which I have 
many a time assured myself. 

The name entire is generally given to beers that have been mingled ; 
while stout is applied to one that is prepared with more care and is des- 
tined for more delicate consumers, though it participates in the general 
characteristics that we have just described. 

Under the name ale are classed all the other varieties of beer that do 
not possess a deep color, and are not prepared from excessively roasted 
malt ; hence, they are richer in saccharine matter and alcohol ; and as fer- 
mentation has not progressed far enough to destroy all the sugar they con- 
tain, they possess a very different flavor froni that of porter, and present 
no tendency to sour. 

Thus, we may divide into two great classes the beer that is used in the 
United Kingdom : the first class is rich in color, but poor in alcohol, de- 
prived of sugar, and ready to undergo acetic fermentation ; they are also 
impregnated with a principle obtained by the torrefaction of grain, and 
which perhaps is not alien to their pathogenic properties. To this class 
belong the beverages known under the generic name of porter, and whose 
use so markedly predisposes to gout. 

The second class, on the contrary, though poor in color, are rich in al- 
cohol, and do not contain a trace of acetic acid. 

It is understood, of course, that in this brief account we could not include 

1 " Probably because the London porters first used it." — Webster. 



94 CLINICAL LECTURES ON 

all the variation to which caprice, chance, or local customs may have given 
rise. In England, the beer of one county or shire does not resemble 
that of its neighbor ; and each distinguished brewer has his secrets, which 
especially stamp the products of his manufacture. It is enough, then, to 
have presented the reader with a general view of the subject, without en- 
tering into a minute study of details. 



THE DISEASES OF OLD AGE. 95 



LECTURE X. 

PATHOLOGY OF GOUT. 

Summary. — Rational Theory of Gout — It can hardly be Formulated in the Present 
State of Scientific Knowledge — Cullen — Discovery of Lithic Acid (Uric Acid) — 
Influence of this Fact upon Modern Works— Garrod's Researches — He establishes 
the Fact that Uric Acid exists in Excess in the Blood of Gouty Patients — Origin 
of this Excrementitious Product — It is still but little known — Are Urea and Uric 
Acid Immediate Products of Disassimilatiou ? — Experiments of Zalesky. 

Empirical Researches— Effects of Fasting — Animal Diet — Exercise — Contradic- 
tory Results in this Respect — Influence of Liquors : Experiments of Booker. 

Theory of a Gouty Attack (Fit)— The Articulations preferably affected — Fibrous 
Tissue, Cartilage — Predilection of Gout for the Great Toe — Successive Invasion of 
Joints — Tophi — Deposits of Urate of Soda in the Cartilages — Pain — General Re- 
action — Visceral Phenomena — Insufficiency of our Knowledge in this Respect at 
the Present Day. 

Gentlemen : — After havirig passed in review the various causes which 
are closely or remotely associated with the production of gout, there re- 
mains for us to seek a rational theory of this disease, and to combine the 
data of physiology with those furnished us by clinical observation. We 
may not, besides, flatter ourselves that we can obtain complete success in 
this direction ; for, even though we know the morbid principle whence 
arises, in this case, the pathological series of events, we are yet far from 
grasping all the links in the chain ; the conditions presiding over the for- 
mation and elimination of uric acid are still unknown to us, and will, no 
doubt, long elude our investigations. 

In order to understand, however, the present state of the question, it is 
necessary to trace the various phases it has passed through during the 
course of years until the present day. Let us see, then, what the opinion 
of our predecessors was in this respect. 

The theories which were formulated concerning gout during all the 
seventeenth and part of the eighteenth century were essentially associated 
with humorism ; this is always the theory of Sydenham, in slightly differ- 
ent words. There is morbific material in the body, the result of imper- 
fect digestion occurring either in the primce vice or in the secondary appa- 
ratus, and the efforts of nature to eliminate this peccant material (phlegm, 
bile, tartar) constitute the symptoms of gout. 

But a reaction against these old ideas set in from Cullen's time. This 
celebrated author held that there was no proof of the existence of a morbific 
material in the blood. He regards tophi, adduced by the humorists in 
support of their theory, as purely accidental occurrences. For him, gout 
results from a sort of plethora, with loss of tone in the extremities. 

The progress of chemistry stepped in to modify, to a certain extent, 
this method of regarding the disease. In 1775, Scheele discovered lithic 
acid (uric acid) in urinary calculi and in the urine ; in 1793, Murray Forbes, 



96 CLINICAL LECTURES ON 

by reason of the analogies subsisting between gout and gravel, promulgated 
the view that uric acid existed in the blood of the gouty ; in 1797, Tennant 
and Wollaston established the composition of tophi to be of urate of soda. 

Cullen's theory, however, still held sway in England. Scudamore con- 
tinued to regard gout as a sort of plethora without any relation to the ex- 
cess of uric acid in the blood ; he considers tophi as exceptional phenomena 
in gout, having found them in but forty-five out of five hundred gouty 
subjects. Barlow and Gairdner share this opinion ; and recently Barclay l 
has again recurred to this point, relying, it must be said, much more on 
sentiment than upon observation. But Parkinson, Home, and Holland are 
identified with the uric acid theory. 

In France, gout has been studied only by a limited number of writers ; 
but those who have devoted themselves to this subject admit, at least theo- 
retically, the presence of uric acid in the blood, and fully understand the 
importance of this cardinal fact. In this connection we may especially cite 
Andral, Bayer, and Cruveilhier; 2 the latter regards the deposit of tophaceous 
matter in the interior of the articulations and in their vicinity as the char- 
acteristic lesion of gout. Now, these tophi consist of urate of soda ; and 
Cruveilhier is thus led, he says, in spite of himself, to the theory of Syden- 
ham and the older investigators : he regards urate of soda as the material 
cause of gout, and he considers that there is no doubt but that the first 
attack of gout coincides with a secretion of this product, which is 
afresh with each subsequent attack of the malady. 

Notwithstanding all the interest offered by the works we have just men- 
tioned, the period of positive knowledj date from Garrod'i 
investigations in 1848. This observer, so often quoted in the course of 
these lectures, has established : fint, that in acute or chronic gout th- 
an excess of uric acid in the blood: secondly, that from the first attack 
there is a deposition of urate of soda in the joints ; thirdly, that during the 
attack or paroxysm there is an appreciable diminution in the excreta 
uric acid by the kidneys. 

These are the fundamental facts that may serve as elementary princi- 
ples of a pathogenic doctrine ; but there is still no physiologic*] du- 
gout in it. A few attempts, however, have been made in that direction, and 
I shall present you with the chief results thereof. 

I. — The presence of an excess of uric acid in the blood does not consti- 
tute gout, 3 but merely induces a marked predisposition to this malady. 
"We must, then, study the various circumstances that may augment 
proportion of this excrementitious product ; but we are met with difficul- 
ties at the very first step. 

What is the origin, what are the sources of the uric acid exert: 
Authorities do not agree concerning this point. 

A. — The theory of direct combustion, advanced by Liebig, seems to af- 
ford a ready solution to the problem. Uric acid has its origin in the I 
itself, at the expense of the albuminoid matters (fibrin, albumen, globulin) 
which have not been oxidized sufficiently to convert them into 



1 On Gout and Rheumatism, p. 3 and following. London. 181 

2 Andral: Precis d'Anatomie Patbclodque. Vol. i.. p Vol. ii.. | 
1829. Rayer: Trait:- des Maladies des Reins. Vol. L, p. 843. Pw 
veilhier : Atlas d'Anat. Pathologique. Tart 4. Plate iii. 

s Albuminous nephritis and the saturnine cachexia are also among the number of 
diseases accompanied by an excess of uric acid in the \ 



THE DISEASES OF OLD AGE. 97 

Here is an excess of receipts over expenses ; an individual has eaten too 
much, taken too little exercise, and hence, gout is developed. 

But it has been recently proved that it is always the urea which in- 
creases, and not uric acid ; and besides, according to the researches of 
Bischoff and Voigt, these two products are the result of the disassimila- 
tion of the elements composing the tissues, and are never directly formed 
in the blood. 

B. What, then, are these organs, what are these tissues from which uric 
acid is formed ? Again we find ourselves in the face of contradictory re- 
sults. 

Urea comes from the muscles, we are told, and uric acid from the pa- 
renchymatous viscera ; and, indeed, it has been found in brain and liver, 
in the spleen (Scherer), and in the lungs (Cloetta). A few pathological 
facts tend to confirm this idea : thus, Uhle and Banke found an actual ex- 
cess of this acid in the urine in a case of splenic leukaemia ; and Harvey 
obtained the same result in diseases of the liver. 

Other physiologists say that urates arise from cartilage and fibrous 
tissue, and organic movement is certainly less active in them because of 
their scanty vascular structure, as Bartels ' has remarked ; consequently, 
oxidation takes place in an incomplete manner. The investigations of 
Professor Robin 2 have led to an analogous result. He admits that in 
fibrous tissue the albuminoid materials are changed into glutin ; and this 
substance, in its turn, breaks up into uric acid and urates by a process of 
disassimilation. Hence, it is evident, that when the work of disassimila- 
tion is exaggerated in these parts, the result will be a satiu*ation of the blood 
with these products — in other words, a uric acid diathesis. 

Professor Robin has also found uric acid in normal fibrous tissue ; 3 
and hence, the pathological condition is to him nothing but an exaggera- 
tion of what occurs in a state of health. He explains, in this way, why the 
articulations are the principal seat of the lesions in gout : their richness in 
fibrous tissue renders them unusually liable to be attacked in the disease. 

Without denying the plausibility of this explanation, let us remark 
that the theory according to which uric acid and urea are the immediate 
products of disassimilation is certainly deserving of respect, although after 
all it is merely an hypothesis. Its foundation rests especially °on the 
presence of these two substances in normal blood ; but they are found 
only in the minutest proportion in mammals, while in birds and reptiles 
they seem wholly wanting. 4 The presence of urea and uric acid in the 
tissues has also been advanced in support of these ideas ; but as for urea, 
this is not the fact, except in morbid states ; in the normal condition of 
affairs kreatin and kreatinin alone are found in the muscles. Concerning 
uric acid, the case 4s better proven. 

In any event, the investigations of some of the modern scientists seem 
to invalidate this hypothesis. According to Zalesky, urea and uric acid are 
formed in the kidney at the expense of kreatin : tie the ureters in a dog, 
and you will have an accumulation of urea in the blood ; extirpate the 
kidneys, and there will be no such phenomenon. In reptiles there will be 
an accumulation, not of urea, but of uric acid, when the ureters are ligated ; 

1 Deutsche Archiv fur klin. Med., Bd. i., Heft 1, p. 13. Leipzig 1865 

2 Dictionnaire de Med. (de Nysten), p. 678. 1865. Programme du Cours d' Histolo- 
gic, p. 90. 1864. 

3 A verbal communication from Professor Robin. 

4 Zalesky : Untersuch. iiber den uramisch. Process. Tubingen, 1865. Recent re- 
searches of G-rehaut appear to invalidate the results obtained by Zalesky 



98 CLINICAL LECTURES ON 

but ablation of the kidneys is followed by no such occurrence. Zalesky 
concludes therefrom that urea (in those animals that secrete it) and uric 
acid are formed within the kidney itself, and have not previously existed 
in the blood. 

In this direction, then, we do not find any really important data, any 
really solid foundation upon which we can establish a rational doctrine, 
and hence we must have recourse to other means of investigation. 

II. — The purely experimental research into the conditions which induce 
a variation in the proportion of uric acid in the renal excretion at least 
furnishes us with some interesting information. 

The proportion of uric acid increases after a meal (Bence-Jones) ; fast- 
ing diminishes it by one-half, and a vegetable diet acts in a similar manner. 

All authors since Lehmann agree as to the effects of a purely animal 
regimen ; there is an increase of uric acid and urea, but especially of the 
latter product. 

Theoretical deductions seem to accord quite closely, up to this point, 
with the data furnished us by observation from the standpoint of gouts 
etiology. But in proceeding with this study we shall very soon encounter 
contradictions. 

It is, for instance, a generally admitted fact that exercise is one of the 
best means for preventing the uric acid diathesis. Lehmann's experiments 
confirm this view ; he has established beyond all dispute that muscular 
activity results in an augmentation of the quantity of urea and a diminu- 
tion in the proportion of uric acid. These results have been confirmed in 
the case of urea, but contradicted concerning uric acid. Beneke, Genth, 
and Heller ' found that prolonged exercise during three hours had the 
effect of increasing the quantity of this product Ranke,* and Speck admit 
that unusual activity may be followed by the same results. And, in the 
main, however violent or prolonged the work may be, there is rati., 
increase than a diminution of uric acid. 

Concerning the activity of the respiratory functions, it is generally 
admitted that the more this increases, the greater is the diminution in uric 
acid, while the proportion of urea is augmented. Still, it must be acknowl- 
edged that this view rests upon no very well established facts.' 

In spite of the interesting experiments of Bocker, 4 we cannot as 
conclude anything concerning the influence of alcohol. According to this 
investigator, alcohol and spirituous liquors diminish the production of urea 
and urea acid ; wine, on the other hand, tending to increase it, as the pre- 
vious experiments of Liebig had already proved. When beer does n 
as a diuretic, it diminishes the quantity of urea and increases that of uric 
acid, but only very slightly. Finally, tea and coffee diminish the propor- 
tion of this substance. If, in these experiments, it be admitted that the 
quantity of uric acid passed in the urine corresponds to that formed in the 
economy — which is quite probable, since the subjects who have aided in 
attaining these results were in full health — it can be proved that al 
and spirituous beverages act here wholly different from beer and wine, 
agreeing thus with the data of clinical observation. 

1 Beneke : Nord See Bad., p. 35, 1835. Genth : Untersuch. iiber den Einfluss der 
Wassertrinkens auf dem Stoffwechsel. Wiesbaden, 1S56. Heller: Heller's Archiv 
Neue Folge. 

- Ranke : Anssch. der Harnsaure. Miinchen, p. 240. 1 E 

3 Consult Parkes : On the Urine, pp. 50 and o20. 

4 Bocker: Beitrage zur Heilkunde. Vol. i., p. 240. 



THE DISEASES OF OLD AGE. 99 

Upon the whole, contemporaneous chemical and physiological sciences 
have not yet shed a very brilliant light upon the all-important question in 
gout, namely, the presence of uric acid in the blood. 

Since, however, the reality of the latter phenomenon has been experi- 
mentally proved, can we, accepting this as a starting-point, deduce from it 
the other symptoms of this disease ? This has been the aim of Garrod's 
endeavors ; and we shall exhibit the results of his labor, asking you to no- 
tice, however, that it is now no longer a deduction of a general theory of 
gout, but only the question of an attack. 

m. — We have already seen that various circumstances are preparatory to 
the occurrence of a gouty attack and render it imminent. Some have the 
effect of accumulating uric acid in the blood, either by directly favoring the 
production of it (excessive meals and abuse of certain beverages), or by di- 
minishing the excretion of this product (lead-poisoning, painful emotions). 
Others, again, attack the solubility of uric acid in the blood by diminish- 
ing the latter's alkalinity ; such are the impression made by cold, checking 
the acid secretion of the sweat, and the use of acids, vinegar, etc. 

We may suppose, then, that the presence of an excess of uric acid 
abruptly thrown into the circulatory stream explains the nervous derange- 
ments, the dyspeptic and other premonitory symptoms which immediately 
precede an attack of gout. 

Up to a certain point the local symptoms may also be referred to a simi- 
lar explanation. We shall now review the most important of these phe- 
nomena, assuming, for that purpose, a standpoint such as we have just 
described. 

Gout preferably affects the articulations. Here is a point of similarity 
with other dyscrasise which have a predilection for the joints. We see this 
in purulent infection, in glanders, and in the therapeutical exhibition of ar- 
senic ; and lactic acid introduced into the veins seems also to expend its 
action upon the joints (Kichardson). 

Gout preferably affects fibrous tissue, and especially cartilage. This 
unpleasant prerogative may be attributed to their scanty vascular structure 
and to the relatively slightly alkaline reaction of their own tissue — two cir- 
cumstances which clearly favor the formation of those crystalline deposits 
characteristic of the disease. 

Gout preferably invades the metatarsophalangeal articulation of the 
great toe. This perhaps arises from the fact that the joint is one of the 
farthest from the circulatory centre ; and it also undoubtedly occurs be- 
cause this articulation is often called upon to support the entire weight of 
the body, frequently presenting lesions before any gouty manifestations ap- 
pear. It is well known, besides, that traumatic causes have the effect of 
inducing the invasion of gout. 

We can explain, to a certain extent, the successive implication of the 
articulations, for when extensive deposits have formed upon the cartilages 
of a joint, it may be said that this point is saturated ; whereupon the other 
articulations take it up, following a more or less regular order. 

Tophi also acknowledge as their cause a saturation of the cartilages ; 
and thus their formation is always a subsequent phenomenon. 

It may be asked whether the deposits of urate of soda in the cartilages 
are the cause or the effect of the local inflammation. Garrod inclines 
toward the former view. He says that the inflammation excited by these 
deposits seems to have the effect of destroying the urate of soda, and that, 
following an attack, the blood contains considerably less of this salt. J3e- 



100 CLINICAL LECTURES ON 

sides, the deposits which form externally are not preceded by inflammatory 
action, and, even if they sometimes give rise to symptoms of this nature, it 
is solely because they are foreign bodies (external ear). 

And thus the formation of these deposits in the cartilages precedes the 
first attack, while the formation of new deposits, either in the same joint 
or in new articulations, brings about those local phenomena that character- 
ize subsequent attacks. 

But why this excruciating pain inaugurating the series of articular 
symptoms ? It cannot be attributed to inflammation ; local fluxion is pre- 
cisely as intense, but certainly far less painful in articular rheumatism. 
According to Garrod, we must attribute it to the presence of the deposits 
themselves deep in the cartilages, and to the tension which they induce 
thereby ; for only when gout is intra-articular is the suffering so great ; 
when the deposits are external, it is not equally severe. 

Finally, symptoms of arthritis appear, and a general reaction is caused 
by the local phenomena, it being well known that its intensity is usually 
in proportion to the number of articulations attacked and the degree of 
local inflammation. 

Such, gentlemen, is the state of our knowledge upon this subject. I 
have considered it proper to devote myself to a discussion frequently 
ren, in order to show you how much progress, in this 
remains for us to make. 

Concerning visceral gout, we have previously described the resul* 
Zalesky's interesting experiments ; these have shown us that the ligation 
of the ureters induces, in many animals, the formation of deposits of ni 
soda in the stomach-follicles. It is highly probable that in man the <: 
intestinal juices are loaded with urates, in cast- of saturation. Undoubt- 
edly, analagous phenomena might also be produced bearing on I 
points. In those animals upon which he experimented. Zalesky found a 
large proportion of urate of soda in the muscle-extract We all n 
understand the importance of these facts from the standpoint of gout's 
visceral symptoms, but what is less easily explained are the sudden I 
stases which cany the morbid action from one point to another — from the 
great toe to the stomach, and from the stomach to the joints. Concerning 
this point, science has certainly not pronounced her last dictum. 

It yet remains for me to speak of the therapeutical measures which we 
can employ against gout, but I prefer to leave this until we take up the 
treatment of chronic rheumatism ; for, by thus twinging them together, 
we shall find the elements of a comparison as curious as it is instruct] 



THE DISEASES OF OLD AGE. 101 



LECTUKE XL 

CHRONIC ARTICULAR RHEUMATISM AND ITS ANATOMICAL LESIONS. 

Summary. — Chronic Articular Rheumatism Essentially a Hospital Disease — Nature of 
the Malady — Relation to Acute Rheumatism — Principal Varieties of this Affection 
— Chronic Progressive Articular Rheumatism (Gouty Rheumatism) — Chronic Par- 
tial Articular Rheumatism — Heberden's Nodes ; not to be confounded with Gout. 

Anatomical Characteristics of Chronic Articular Rheumatism — Necessity of a 
Careful Study of the Local Lesions — Unity of the Disease — Earliest Works Rela- 
tive to this Subject. 

Fundamental Characteristics of Chronic Rheumatismal Arthritis — Changes in 
the Synovial Membrane ; in the Articular Cartilages; in the Intra-articular Fluid ; 
in Osseous Tissue— Histological Study of these Different Lesions— Modifications cor- 
responding to the Chief Clinical Forms of the Disease. 

Gentlemen : — After having thoroughly studied the history of gout, we 
are now about to take up a disease so closely allied with it, that very fre- 
quently the two conditions have been confounded ; but we hope to be able 
to prove to you that this similitude is without foundation, and that chronic 
articular rheumatism has a place reserved for itself apart from gout. 

With regard to chronic articular rheumatism, the succeeding subject 
of these lectures, we enjoy a great advantage ; for, while gout is not one of 
the diseases commonly met with in the hospitals of France, and is, besides, 
an affection quite infrequent in the female sex — while gout is almost un- 
known in the Salpetriere, chronic rheumatism is, % on the contrary, one of 
the commonest infirmities in this institution ; and indeed, this disease 
prevails among women and among the least-favored classes of society. In 
this way the proportion of patients admitted to the hospital for this kind of 
lesion is about one-fifteenth of the total number of inmates. 

Most of those authors who have made a special study of this disease 
have drawn on institutions analogous to the Salpetriere for their observa- 
tions. In England the ivorkhouses furnished the interesting materials for 
Colles, Smith, and Adams' publications. It was, you know, in the Salpetri- 
ere that Landre-Beauvais wrote the monograph which we have already had 
occasion to quote. We are about to undertake, then, a truly clinical study, 
and I shall frequently have the opportunity to present you, not only with 
anatomical specimens, as has so often been done up to this time, but 
even with patients who are suffering the lesions I shall describe to you. 

I. — The name I have chosen to designate the disease in question sanc- 
tions a nosological interpretation which I unreservedly maintain, but which 
all authors do no admit. 

Among the adversaries of the opinion which I hold, some declare that 
we have here to do with a special disease, one completely independent of 
gout and acute articular rheumatism : this is Garrod's rheumatoid arthritis 
and the rheumatic gout of Fuller. Others again, consider the various forms 
of nodular rheumatism as subordinate to gout. 



102 CLINICAL LECTUPwES ON 

I shall endeavor, gentlemen, to justify the ideas which I uphold, and to- 
show you that chronic articular rheumatism is sometimes seen, at the bed- 
side, proceeding directly from the acute form, precisely as chronic lobar 
pneumonia may follow acute pneumonia. The fact is, however, that the 
chronic form of articular rheumatism almost always develops spontaneously, 
and without passing through the acute fonn ; but this negative fact can- 
not invalidate the connection we are endeavoring to establish. 

As for gout, we shall institute, later on, a radical distinction between 
the two affections. 

II. — Chronic articular rheumatism appears in various aspects, and of 
such dissimilar appearance that many authors have concluded that several 
different diseases are presented them. We, however, only see in them the 
various forms of one and the same affection. 

To give but a single illustration, it is enough to state that many writers 
are ready to admit that nodular rheumatism is nothing but a poly-articular 
rheumatism in the chronic stage ; but they refuse to recognize a rheuma- 
tismal origin for the disease when it is localized in a single joint, and there 
slowly and insidiously produces the grave and deep-seated lesions of m 
coxce senilis. 

We hope to be able to prove to you that it is quite impossible to make 
an actual distinction between the various forms of rheumatism, but that, 
on the contrary, it is frequently possible to show that they all proceed 
from one and the same source. 

It is, however, indispensable, from a clinical standpoint, to make a 
separate study of the principal varieties of chronic rheumatism, just 
it were really a question of several distinct diseases ; this is the only way 
to avoid confusion. And this preliminary work finished, we shall endeavor 
to demonstrate the common tie binding them together. 

There are numerous types of chronic articular rheumatism ; but we 
shall devote our attention chiefly to the following : 



1. Clxronic Progressive Articular Rheumatism. 

This is the gouty or nodular rheumatism of certain authors : the/>rn 
asthenic gout of Landre-Beauvais, and Haygarth's nodosities of joints. This 
is the gravest form of the disease, being accompanied by deplorable in- 
firmities. Although exhibiting a preference for the smaller joints. i: 
also invade the large ones ; and it frequently induces muscular retractions 
and other symptoms. 

Two kinds may be distinguished : tins disease, sometinies/>n?>ion/, some- 
times secondary to the acute (the latter rare, however), may be either be- 
nign or malignant. 

It is not always concentrated in the joints, but may be accompanied by 
visceral diseases, at times analogous to those of acute rheumatism 
sionally proceeding therefrom), and at others again by those peculiar to 
chronic rheumatism ; in the latter category we must place ophthalmia and 
albuminous nephritis. 

The local changes are those of a dry aiihritis. which are, besides, except- 
ing a few secondary modifications, common to all the forms of chronic rheu- 
matism. 



THE DISEASES OF OLD AGE. 103 



2. Partial Chronic Articular Rheumatism. 

The joints affected in this variety are few in number, sometimes only- 
one. The articular changes are the same as in the preceding variety, but 
are much graver, as seen in the case of morbus coxce senilis. Foreign 
bodies, which sometimes develop within the' joint, are frequently, in such 
cases, of an exceptional size. 

Visceral implication or abarticular affections are, on the contrary, quite 
infrequent here, although they sometimes do exist. It is in the benign 
form of the disease that we are especially liable to meet with them — certain 
forms of asthma, and skin diseases, occurring in some of its subjects. In 
the malignant form, where visceral affections are rare, and where the whole 
disease seems to be concentrated upon the affected joint, the case is wholly 
different, although albuminuria has been seen in a few exceptional cases. 



3. Heberden's Rheumatism. 

Heberden's nodosities (digitorum nodi) constitute the mildest type of 
this disease. 

It is at this point especially that it becomes necessary to enter into a 
critical discussion. When it is a question of nodular rheumatism, the dif- 
ference from gout, at least in certain characteristics, is generally conceded ; 
but it is not the same with the variety we are describing. It may be said 
that no one doubts but that these lesions are certainly and consistently re- 
lated to gout. We are constrained to hold a diametrically opposite opin- 
ion ; and we purpose to describe in a very painstaking manner the arthritis 
which preferably attacks the second articulation of the fingers, deforming 
them in such a strange fashion. 

These lesions have certainly engaged the attention of many an investi- 
gator, but they have not yet been studied with all the care they deserve. 
Pathological anatomy will very soon enable us to recognize that, excepting 
their special seat, these arthropathies differ in no way from those which 
constitute the two preceding types ; and we shall eventually have the op- 
portunity to justify, from a clinical point of view, the separation of this 
particular type from them. 

It is enough, at present, to observe that in ordinary cases we meet here 
only with nodosities of the terminal phalanges, almost always indolent and 
without any complication. Sometimes, however, there are several other 
joints, some of which are among the most important articulations, that are 
simultaneously affected ; and indeed, the articular lesion may be accom- 
panied by muscular or neuralgic pains ; sometimes in the sciatic, the tri- 
facial, or in other nerve-trunks. 

Among the visceral diseases which may occur in this variety, we may 
especially indicate asthma and megrim. 

HI. — We are now about to consider the anatomical characteristics of 
chronic rheumatism. 

When we attempted to sketch the history of gout, we met at the very 
commencement a fundamental fact which governed all the symptomatic 
manifestations of the disease — we mean the change in the blood from an ex- 
cess of uric acid. We find no characteristic with such a general bearing to 
guide us in the study of chronic rheumatism ; and although it is probable 



104 CLINICAL LECTURES ON 

that a special modification in the fluids of the economy exists in rheuma- 
tism as well as in gout, the hypothesis is still far from having been demon- 
strated. 

A thorough and careful examination of the local lesions is, therefore, 
what we -must here have recourse to ; and we shall pursue our researches 
from the dual standpoint of the clinic and pathological anatomy, though 
laying especial stress, for the 1 time-being at least, upon the latter aspect of 
the question. 

In the first place, pathological anatomy enables us to establish the unity 
of this disease ; for the various forms it may assume are distinguished by 
clinical characteristics principally, presenting, with respect to local changes, 
a common type modified by a few differences of lesser import. In the sec- 
ond place, it enables us to unite the chronic with the acute or subacute 
form of articular rheumatism; and finally, to demonstrate a radical differ- 
ence between this affection and those other diatheses, which, along with it, 
enjoy the privilege of localizing around the joints ; such, for example, are 
gout, scrofula, and syphilis. 

We are not compelled to go very far back in history to meet with the 
first works bearing upon our subject. 

The physicians of antiquity, as we have already remarked, seem to have 
confounded articular rheumatism with gout, and we may ask ourselves 
whether the first of these two diseases is not one of those peculiar to mod- 
ern times. Archaeology comes to the aid of medicine on this question, and 
Pompeiian excavations tell us that chronic rheumatism was already in ex- 
istence during the first century of the Christian era. Delle Chiaje, in a 
work entitled "Osteologia Pompeiana," has depicted articular Lesions iden- 
tical with those which are found in the plates of Adams' HlMwiffll work. 
Concerning this point, then, there can be no doubt whatever ; but eluonic 
rheumatism was not recognized as a separate morbid species until the time 
of Sydenham and Musgrave, and the first monographs devoted to the study 
cf this question date from the commencement of this century. Wi 
quote in particular that of Landre-Beauvais (an "NTH.), Haygarth (1809), and 
Chomel (1813). A little later on the fundamental features of chronic rhcu- 
matismal arthritis were published ; in France, Lobstein ( 1 aking 

with reference to arthritic osteojjsathi/rose ' noticed that the bones in this 
disease were especially fragile, that destruction of the articular car- 
was followed by eburnification, and that osseous vegetations formed around 
their articular extremities. About the same time an Irish physician. 
Colles, remarked that this inflammation differed from others by a very es- 
pecial characteristic ; he says: "Two very different pi aking 
place at the same time, namely : absorption of the old bone audits articular 
cartilage, and the formation of new osseous tissue. " 

But to Adams, 2 a contemporary and countryman of Colles. we are 1 1 
cially indebted for the best studies that have 'been made of this subject 
(1839-57). So far as examinations by means of the naked eye are con- 
cerned, his descriptions leave but little to be desired ; but a special men- 
tion is due the works of Deville and Broca upon dry arthritis (1850). In 
certain respects they completed the descriptions given by Adams. In our 
days histological investigations have shed a penetrating light upon this 
question. 

1 Osteo-psat7iy?-ose : a condition of bone accompanied by extreme fragility, and 
probably the fragilitas osseum of English, and the 06 in and some 

French authors.— L. H. H. 

8 A Treatise on Rheumatic Gout. By R. Adams. K. D. . etc. London, 1 v 



THE DISEASES OF OLD AGE. 105 

In Germany, Zeis, H. Meyer x and Otto Weber, 2 tell us how each tissue 
is changed under the influence of chronic rheumatism, and have in this 
way suggested reasons for many phenomena that otherwise would have 
remained unexplained. 

In France, Ranvier, Cornil, and Vergely, 3 have confirmed and cleveloped 
the results of these investigations. 

It is by means of these documents, and the studies we ourselves have 
made, that we shall describe to you the morbid action that characterizes 
chronic articular rheumatism. 



A. SUMMAKY OF THE FUNDAMENTAL CHARACTERISTICS OF ChEONIC RhEUMATISMAL 

Arthritis. 

The disease we are about to study involves all the structures that con- 
stitute the joint, but it is first exhibited upon the synovial membrane and 
the articular cartilages; these two parts may be affected simultaneously or 
in succession. The synovial membrane becomes extremely vascularized ; 
the pre-existent synovial fringes increase in size and there is a formation of 
new villous appendages; and finally, foreign bodies may develop, either at 
the expense of the fringe-like processes themselves, or deep within the syno- 
vial membrane. 

There is, at the same time, a change in the synovia of the articulation: 
at first there is an increase in the secretion of the fluid, and this, according 
to Adams, is a constant occurrence. Later, the intra-articular fluid may 
undergo various changes, but it never contains pus, except when certain 
complications exist. Destruction of the articular cartilage occurs in a 
manner already known to William Hunter, and thoroughly studied by Red- 
fern; 4 it passes under the name of the " velvety " change. 5 The cartilages 
are first seen to break up into a fibrillar structure, then these fibrils them- 
selves disappear, and the cartilage is destroyed. 

Now, let us see what are the changes occurring at the same time in 
the osseous tissue. There is, first, eburnation of the articular surface, 
either at the expense of the deeper portions of the cartilage or of the pre- 
existing bone ; osseous vegetations simultaneously occur, located, most 
commonly, at the extremities of the cartilage. These osteophytes have, at 
first, a cartilaginous structure, but soon are impregnated with calcareous 
salts, finally ossifying. 

A third change, whose importance at least equals that of the preceding 
lesions, is the rarefaction, the decrease in density, of the osseous tissue at 
the articular extremities. At first there is marked vascularization beneath 
the layer of ivory-like substance, and a bony marrow of new formation de- 
velops at this point ; secondly, the bone becomes very much less dense, and 
is transformed into a kind of fatty marrow underneath this spot. 

These are the fundamental facts which it is important to state here. 
There are, no doubt, many other alterations ; but, since they are not com- 
mon to all the forms of articular rheumatism, we shall reserve their study 
for a more suitable occasion. 



1 Miiller's Archiv. 1849. 2 Vir chow's Archiv, p. 74. January, 1858. 

3 Ranvier: Theses de Paris. 1865. Cornil (translation of Niemeyer : Pathol. In- 
terne. Vol. ii , p. 556. Vergely : Theses de Paris. 1856. 

4 Edinburgh Monthly Journal. 1849. 

5 The numerous fibril la? at right angles to the articular surface give to the latter 
a velvety appearance. — L. H. H. 



106 



CLINICAL LECTURES ON 



At present we shall take up each point just described, and study it in 
a more thorough manner, aided by all the means of investigation which 
to-day are at our command. 



B. — Histological Study. 



I t — Changes in the synovial membrane. — To a certain extent, these altera- 
tions merely consist in an exaggeration of the condition existing normally 
in a rudimentary state. 

It is well known that the synovial membrane has fringe-like processes 
which themselves present appendages. 1 In the pathological state these 
little prolongations are seen increased in number, and presenting a greater 
vascularity. 

Normally, there are cartilage-cells in these synovial appen K., Hi- 

ker). These cartilaginous nuclei may become the starting-points for those 
pediculated foreign bodies of which we have already spoken. According 
to Eanvier, there is, first, cell-proliferation ; then the formation of true car- 
tilage ; calcification next takes place ; and finally we have ossification prop- 
erly so-called, with bone-corpuscles. 

Within the deeper structure of the synovial membrane sesrife bodies may 
be developed, passing through precisely the same phases as those which 
are pediculated. 

2. Changes in the cartilage. — "With regard to articular cartilage, we find 
ourselves confronted by two principal facts : the 
first \b proliferation of cells, and the formation 
of secondary capsules ; the secoi. 
tion of the fundamental tissue. It breaks up 
into fibrils which are free at that extremity cor- 
responding to the articular cavity. 

This pathological process ought to be stud- 
ied on tin of the cartilage, and in its 
deeper paj 

Upon the surface this segmentation has the 
effect of opening a passage for the capsules of 
the cells, and then the contents of these cap- 
sules escape into the articular cavity. They are 
frequently found along with a dibris of epithelial 
cells (Rindfleiseh, O. Weber), and at other times 
they undergo colloid inetainorph- 

Concerning the' fibrils of the cartilage's fun- 
damental substance, they undergo inuoous de- 
generation or softening, and are transformed 
intomucosiu (Rindfleisch), which 
in considerable quantities in the articular fluid. 
Again, those portions of the cartilage I 
altered are very gradually worn away by articular rubbing, finally drop- 
ping off and laying bare the bony surf a/- 

Within the deeper parts cell-proliferation results in the formation of a 
new bony layer ; the primitive capsules become infiltrated with calctt 
matter and open into the superficial medullary spaces ; the cells which 

1 K611iker: Elements d' Histologic Humaine, trans, of lk-elard u 
Paris, 1856. 




Fig. 12. — Nodular rheumatism: 
surface of a cartilage from a phalan- 
geal articulation. (After Ilanvier). 
a, primary, filled with secondary 
capsules ; b, segmented fundamental 
substance. The primitive capsules 
have just emptied their contents upon 
the free surface of the cartilage. 



THE DISEASES OF OLD AGE. 



107 




contain become the embryonic cells of the marrow, and at their expense 
there is formation of new osseous tissue. 

In this way eburnation of the surface occurs ; it is a sort of sclerosis of 
the bone, accompanied by vascularization of the deep parts. Here we no- 
tice a strange phenomenon taking place, and one recalling, in a certain 
rough way, the facts observed by 
geologists relative to the action of 
glaciers upon rocks. The ivory- 
like surfaces present stripe — radiat- 
ing lines that are of greater or less 
depth in the direction of articular 
movements, and thus evidence an 
imperfect repair in the presence of 
the wear (" usur ") occasioned by 
the constant rubbing of the surfaces. 

The articular cartilage, as you 
know, is covered at its peripheral 
portion with synovial membrane. 
According to Ranvier, this condi- 
tion, in cases where the articulation 
is invaded by rheumatism, hinders 
the capsules opening into the artic- 
ular cavity and pouring then* con- 
tents into it. But they continue, 
then, to proliferate at the spot, 
thus determining the formation of 
those rounded swellings or pads 
which are noticed on the part, and 
which, at first cartilaginous, ulti- 
mately become osseous. 

Ranvier also ascribes all the new 
bony formations developed under 
such circumstances in cell-prolifer- 
ation of the articular cartilage. The 

periosteum, however, probably assumes a certain share in their production, 
while there may likewise be simultaneous ossification of the articular cap- 
sules, the ligaments, tendons, and muscles. As for the interarticular liga- 
ments — the meniscuses, etc. , they are worn down and made to disappear by 
a mechanism analagous to that which destroys the cartilages — a subject 
which, however, has not yet been sufficiently studied. 

These, gentlemen, are the most general facts that I find necessary to 
describe to you ; but there are numerous modifications in this respect, ac- 
cording to the clinical form of rheumatism under consideration, and to 
some particular circumstances resulting from the very conditions of the 
disease. It is in this way that the changes met with in an articulation en- 
forced to absolute repose differ from those accompanying more or less com- 
plete preservation of movement. We have proceeded until now, under the 
latter hypothesis, but at present we shall study the changes arising in cases 
where the joint is immovable. 

In such instances, according to Adams, eburnation is no longer ob- 
served, but there is a neoplasia of connective tissue at the expense of the 
synovial membrane. According to Forster, the cartilage may also partici- 
pate in this process ; sometimes the fundamental substance may undergo 



Fig. 13. — Nodular rheumatism : deep layer of a 
phalangeal cartilage. (After Ranvier.) a, normal 
capsule ; 6, capsules near bones, enlarged and filled 
with secondary capsules ; c, primitive capsules about 
to open into the medullary spaces and to empty their 
contents therein ; d, osseous substance ; e, marrow 
filling the areola? upon the surface. At this point it 
is embryonic, for the capsules have poured out their 
contents there ; a little farther on it is adipose. 



108 CLINICAL LECTURES ON 

this change ; and again, on the other hand, it may be the cartilage-cells 
that assume the appearance of connective-tissue cells. "Whatever may be 
the value of this theory, we see the formation of embryo-plastic tissue 
uniting the bones together, and, at a certain period, becoming vascularized ; 
then an ankylosis is formed, which is sometimes fibrous, sometimes osseous. 
The latter occurrence is very rare, taking place only in the very small 
joints. 

The influence of prolonged rest has, moreover, the effect of leading to 
atrophy and extreme friability of bone-tissue ; and perhaps there is a dis- 
appearance of the round, pad-like swellings with the corresponding vege- 
tations. This atrophic process, common in general rheumatism, is, like- 
wise, sometimes seen, though rarely, in morbus coxcb senilis (Adams). 



C. — Modifications Corresponding to the Principal Forms of Chronic Ar- 
ticular Rheumatism. 

The description we have just given applies principally to general and 
to Heberden's rheumatism. Here we find the changes of a dry arthritis in 
a rudimentary condition ; but in partial arthritis they present an enormous 
development, and become almost unrecognizable. Immense osseous vege- 
tations are seen to form : as, for example, in Wear- 
ing erosion ("vxur") and eburnation of cartilage and bone are exhibited 
in the highest degree, and eventually result in a deformity of the head of 
the bones. And finally, it is here that atrophy of bone is manifest to the 
very greatest extent — lesions which used to be explained by osteomalakia 
and senile rachitis (Malgaigne, Hattier). 

In those articulations which, for reasons still but imperfectly known, 
admit of the presence of foreign bodies, an immeasurable quantity of these 
is seen developing ; as, for example, in the shoulder and knee ; but it is 
quite the contrary in the case of the hip-joint, or the joints of the fingers. 
There is, besides, considerable thickening of the fibrous capsules, and ossi- 
fication of ligaments and tendons. Let me remark, however, that these 
differences cannot justify a radical separation ; in partial rheumatism there 
is a large number of joints where changes have occurred only in a very 
slight degree, and in general rheumatism some of the diseased articula- 
tions present lesions quite as marked as in the partial variety : this, for ex- 
ample, occurs in the vertebral column. 

To complete this study we must needs institute a comparison, with ref- 
erence to their anatomical points, between chronic rheumatism and the 
other arthropathies of slow development. But, before broaching this sub- 
ject, we desire to point out the analogies which bind the chronic to the 
acute form of articular rheumatism. 



THE DISEASES OF OLD AGE. 109 



LECTURE XII. 

COMPARISON BETWEEN CHRONIC ARTICULAR RHEUMATISM AND THE 
OTHER CONSTITUTIONAL ARTHROPATHIES, FROM AN ANATOMICAL 
STANDPOINT. 

Summary. — Analogy between the Lesions of Chronic Articular Rheumatism and those 
of Acute— Changes in the Joints in Acute and Subacute Articular Rheumatism — 
Sometimes Null and Insignificant, sometimes Manifest — Arthritis with Exudation — 
The Inflammation not Superficial — The Cartilages and Bone may participate in 
the Process — Lesions of the Synovial Membrane — Lesions of the Articular Carti- 
lages — Lesions of Bone — Nature of the Fluid poured out into the Synovial Cavity- 
Analogy between these Lesions and those of Chronic Rheumatism. 

Characteristics that Distinguish Arthritis Deformans from other Arthropathies — 
Arthritis from Prolonged Repose — Scrofulous Arthritis — Syphilitic Arthropathies 
— Gouty Diseases of Joints. 

The Changes in Chronic Rheumatism Lack a Specific Character — They may 
arise from Many Causes Foreign to Rheumatism — They are then almost always 
Mono-articular — Chronic Rheumatism, in the Majority of Cases, a Poly-articular 
Disease. 

Gentlemen : — We are now in a position to compare, from a pathologico- 
anatomical standpoint, chronic articular rheumatism with other diseases of 
joints which develop slowly. 

But, before we undertake such a comparison, it is indispensable that 
we should bring out the points of similarity existing between the changes 
in chronic articular rheumatism and those of the acute form. We shall 
very soon discover that the lesions of chronic rheumatism are, as it were, 
but a higher expression of those which occur in acute rheumatism ; they 
correspond to a more advanced period of the morbid action. 

The analogy we have" pointed out is not, at the first glance, a striking 
one, especially if we compare extreme cases, as for example, flying articu- 
lar rheumatism and morbus coxce senilis ; but it is manifested, on the other 
hand, most unmistakably when we choose for comparison those subacute 
cases that form, from a clinical as well as from an anatomical standpoint, 
a transition between the acute and the chronic form of articular rheuma- 
tism. 



I. — Changes in the Joints in Acute and Subacute Rheumatism. 

In the scholastic language of ancient medical writers, the term subacute 
was applied to acute diseases when they endured more than twenty-one 
days — this being the extreme limit to acute affections properly so-called — 
and they might extend over forty days. Pathology does not tolerate such 
arbitrary divisions, and, under the name of subacute articular rheumatism, 
we shall describe a disease whose development is, in truth, slower than 
that of acute articular rheumatism, and, moreover, diners from it in other 
respects, without, however, being radically removed therefrom. But, it 



110 CLINICAL LECTURES ON 

must also be noticed, this subacute form is already allied to chronic artic- 
ular rheumatism because of certain of its characteristics. 

Thus, in this variety of the disease, the articular affections are more 
stable : fever is less intense, and resembles hectic fever ; the smaller joints 
are frequently affected, and oftentimes a large number of them. It is well 
known that in acute articular rheumatism the case is just the opposite. 
And, finally, visceral diseases, or at least certain classes of them, as endo- 
carditis and pericarditis, are here much less frequently observed. 

Such are the fundamental characteristics of subacute articular rheuma- 
tism. Later on in the course we shall present you with other considera- 
tions bearing on this subject ; but, for the time-being, we wish to indicate 
the lesions which are found in the joints in acute articular rheumatism, 
and also in the subacute form of this malady. 

There were interminable discussions, at a certain epoch, concerning the 
lesions of acute articular rheumatism. Can, or cannot this disease termi- 
nate in suppuration ? Some affirm that articular rheumatism never leaves 
a trace in the joints ; and others assure us that it produces most serious 
lesions, which may induce a purulent arthritis. 

To-day the question is considered to have been considerably exagger- 
ated on both sides, and a sounder appreciation of facts has resulted in 
establishing the truth of this opinion. 

True rheumatismal inflammation of the joints sometimes leaves behind 
it no appreciable change (Grisolle, Maeleod, Fuller), although, iu certain 
cases, on the other hand, it may result iu a purulent arthritis (Bouillard). 
But examples of this kind are very exceptional, and what we meet with in 
the vast majority of cases are the characteristics of an arthritis accom} 
by a sero-fibrinous exudation : the synovial membrane is red and vascular, 
and its cavity contains a serous fluid in which fibrinous floccules fl< 

For a long time it was thought that this was a completely superficial in- 
flammation, and that the synovial membrane alone was implicated < synovitis | ; 
but to-day it has been conclusively established that the cartilages, and even 
the bone, may participate in these changes. 

The synovial lesions will not long claim our attention : we have, 
a more or less pronounced vascularity of the fringe-like processes of the 
synovial membrane, which are present in the normal condition of affairs ; 
and, secondly, a varicose dilatation of their vessels (Lebert). 

The changes occurring in the cartilages possess a much greater impor- 
tance ; we are indebted for our knowledge of them to the interesting work 
of Ollivier and Ranvier. 

It has already been observed (Garrod) that the articular eartilag. 
quire sometimes a certain opacity, and lose their polished appearance, 
their blue color, and the consistence which characterizes them in a healthy 
condition. Ollivier and Ranvier have shown, besides, that frequently 
there are changes which can be appreciated by the unaided eye : such are 
the partial swellings on cartilage that give it a mammillated appearance, and 
sometimes even cause actual erosion. But, in cases where there is no 
change visible to the naked eye, the microscope yet reveals palpable and 
probably constant lesions. 

In the primary stage the most superficial ehondroK me globu- 

lar, and the cell which they contain divides, producing one or two second- 
ary cells. 

Thenceforth no alteration may occur in this condition, and we readily 
understand how, in such cases, the histological elements may return to their 
normal state ; but in a more advanced stage, there l ntation oi the 



THE DISEASES OF OLD AGf:. 



Ill 



fundamental substance in the horizontal direction — a kind of " velvety" con- 
dition marked by little furrows which penetrate more or less deeply into 
the tissue. In the interior of these little grooves of new-formation the 
capsules open and discharge therein the cells they contain ; these too are 




Fig. 14 



Pig. 14. —Acute articular rheumatism : surface of a cartilage from the condyles of the femur. (After 
Ranvier.) The fundamental substance is transversely segmented ; the superficial capsules contain sev- 
eral secondary capsules ; only one remaining normal, enclosing a small cellular mass. 

Pig. 15. — Acute articular rheumatism: surf ace of the inverting cartilage of the patella. (After Ran- 
vier.) The primary capsules of this surface contain several secondary capsules; the fundamental sub- 
stance is transversely segmented ; an oblique strip, raised from the surface, remains floating. 

then seen to mingle with the synovial fluid, therein to undergo mucous 
metamorphosis. In this case there are, as you see, striking analogies with 
what occurs in arthritis deformans. 

But the changes which the bony surfaces present render the analogy yet 
more striking ; in certain cases they seem to take part in the phlegmasic 
action. According to Gurlt, 1 the marrow of the osseous extremities un- 
dergoes decided vascularization attended with cell-proliferation. Hasse a 
and Kussmaul 3 have also alluded to some alterations in the bone and peri- 
osteum occurring in acute articular rheumatism. 

A word yet remains to be said concerning the fluid contained in the 
synovial cavity. Sometimes it has an acid reaction, holding mucosin and 
albumen in 'solution ; fibrinous floccules are seen floating in it, along with 
clots of concrete mucus and globular bodies, some of which are cartilage- 
cells or epithelial cells that have undergone fatty degeneration, while others 
greatly resemble pus-globules ; and indeed, we occasionally find true pus- 
corpuscles in it. In general, however, it may be said that the latter ele- 
ment does not predominate, unless in those exceptional cases where there is 
symptomatic secondary rheumatism, or a rheumatismal arthropathy com- 
bined with the purulent diathesis. 

In fine, if we desire to interpret these phenomena, fibrin and pus-glob-* 
ules correspond to an acute synovitis ; while mucosin is produced by the 
transformation of epithelial cells and the fundamental substance of the 
cartilage. 

These changes, presenting unquestionable analogies with those of chronic 
articular rheumatism, are yet more strikingly similar in the case of the sub- 
acute variety. Thus, in instances where rheumatism had lasted nearly two 
months, I have found thickening of the synovial membrane along with dis- 
tinctly marked villous prolongations ; while erosions and a decided " vel- 
vety " change were met with at several points. 

On a subject who, on the twenty-fifth day, died after exhibiting cere- 



1 Forster : Handbuch der path. Anat., p. 1000. 

I Hasse : Zeitschrift fiir rat. Med. Bd. V. , p. 199-212. 

3 Kussmaul : Arch, fiir physiol. Heilkunde. Vol. xi. 1852. 



112 fCLINICAL LECTUKES ON 

bral symptoms, Bonnet found similar lesions even then. 1 Vestiges of 
these alterations are still found in those who succumb to organic diseases 
of the heart, after having previously had several attacks of acute articular 
rheumatism. There is an imperceptible transition between these cases and 
those where the disease has become decidedly chronic, on account of the 
prolongation or the incessant return of the rheumatismal affection. Then 
there are more profound changes : synovial villosities are developed, foreign 
bodies are beginning to be formed, the articular surfaces are commencing 
to undergo eburnation, and there is a formation of bony vegetations around 
the joint ; finally the bone-tissue becomes friable toward the articular ex- 
tremities. 

Thus it is that we are enabled to prove, from an anatomical standpoint, 
the close connection binding the various forms of articular rheumatism 
among themselves. They are not different diseases ; they are varieties of 
one and the same morbid species. 



II. — Changes in the Joints in Certain Diseases, Independent of Rhkoia- 



And now a word with regard to the characteristics distinguishing ar- 
thritis deformans from other chronic arthropathies. 

First. — Arthritis from prolonged rest. — In the first stage, according to 
Tessier and Bonnet, 2 arthritis from prolonged repose gives rise to the fol- 
lowing lesions : there is a sero-sanguineous effusion into the joint, even fluid 
blood sometimes being found there ; the synovial membrane is inj- 
ecchymotic, and it is said there is sometimes even ulceration of the 
lages. 

But in a more advanced stage I have found that central ulcerations cut 
as cleanly as with a punch, and peripheral ulcerations existed upon the 
articular cartilages. There are no osseous swellings, no fibrous ankyloses, 
but there is a decided rarefaction of the boi. But tin 

characteristic of this arthropathy is the existence of a layer of connective 
tissue covering the articular cartilage throughout its whole extent ; this 
membrane is readily detached from the subjacent surface, and we then 
find cartilage whose cells in the chondroblasts have undergone fatty de- 
generation. This membrane is frequently penetrated by arboreseeir 
cularizations, sometimes advancing toward its central portions ; in this way 
are probably explained the vascularizations of cartilage described by cer- 
tain writers. I have found these lesions in patients who have long been 
stricken with hemiplegia or paraplegia, especially in those parts which re- 
mained uncovered, when articular deformity existed. 

Certain of these changes, you know, are found combined with thoe 
arthritis deformans in cases where the joint is absolutely at rest. Finally, 
we must acknowledge this to be an important question, one which, having 
as yet been little studied, demands further investigation. 

Second. — Fungoid, or scrofulous arthritis. — The investigations of Ban- 
vier 3 establish the fact that fungoid arthritis is widely separated from dry 



1 Bonnet : Traite des Maladies des Articulations. Vol. i.. p. 32ft P*B 

■ Tessier : Memoire sur les Effets de rimmobilite Longtemps ProIongM des A 

lations. Lyon, 1844. Bonnet : Op. cit., vol. i. 

3 Ranvier: Des Alterations Histolosriques du Cartilage dans les Tumours Bla:. 

Paris, 1866. 



THE DISEASES OF OLD AGE 113 

arthritis, even from a standpoint of elementary lesions. And this is proved 
by the study of the characteristic lesions of this disease. With regard to 
the bones and cartilages in arthritis deformans, there is a proliferation of 
the cell-elements ; in fungous arthritis, on the contrary, these elements are 
destroyed, and undergo fatty degeneration just as we see it occur in bone 
and in cartilage-cells. Besides, in a more advanced stage of the disease, 
the distinction is shown in the clearest possible manner ; fungoid arthritis 
gives rise to vegetations of bone and synovial membranes, attended by 
destruction and reabsorption of the cartilages ; and then supervenes caries 
or necrosis of the bone — peripheral abscesses, which surround the diseased 
joint, finally being formed. 

There are, nevertheless, analogies between these two affections. In 
certain cases of scrofulous arthritis there is active proliferation of the carti- 
lage-elements ; but this is a secondary occurrence. Sometimes there are 




<^> 



Fig. 16. — A section perpendicular to the surface of the articular cartilage of the femur : from a child 
With a white swelling. (After Ranvier.) The capsules at the surface each contain a little mass consisting 
of granulations that have accumulated within the cellular corpuscles. This is the change the cartilage un- 
dergoes at the commencement of the disease. 

also produced osseous stalactites, but these are extremely vascular (Bill- 
roth) ; there is a very decided difference between them and the thick, 
blunt-edgfed stalactites, formed like drops of candle-grease, and usually but 
slightly vascular, which characterize arthritis deformans. In this way the 
elementary lesions of the two diseases differ from each other, although 
there are mixed cases in which the two may be combined. 

Third. — Syphilitic arthropathies. — We now pass to the consideration of 
syphilitic diseases of the joints. It is extremely probable that by this de- 
nomination acute or chronic rheumatism occurring in the syphilitic has 
been described more than once, for these two diatheses are far from ex- 
cluding each other. A few clinical peculiarities, however, and the decisive 
influence of specific treatment in certain cases where the so-called rheuma- 
tism has been protracted, have induced some physicians, among them 
Babington, Boyer, and Lancereaux, 1 to think that there really exist special 
arthropathies as the direct results of a venereal infection. 

Lancereaux, to whom we owe a thorough and thoughtful work upon 
this subject, has carefully described the articular lesions of syphilis. He 
distinguishes two forms : (a) secondary arthropathies, which resemble acute 
or subacute articular rheumatism ; and (b) tertiary arthropathies, simulat- 
ing certain forms of chronic rheumatism ; the latter were the only ones he 
was enabled to study from an anatomical standpoint. They commence in 
the subsynovial cellular tissue and in the fibrous tissue, being character- 
ized by the formation of a neoplasm, which from its texture and external 
appearance absolutely resembles the gummy tumors (gummata). 

In those cases recorded by Lancereaux there was no alteration in the 
synovial membrane, although the articular cartilages were eroded. 

Fourth. — Gouty arthropathies. — The lesions of arthritis deformans fre- 
quently offer enough resemblance to those of gout to cause them to be 
easily confounded at the bedside ; but from an anatomical point of view 

1 Lancereaux : Traite de la Syphilis, p. 182. 1866. 
8 



114 



CLINICAL LECTURES ON 



this is not the case. You never find the least trace of a deposit of urate of 
soda, either in the articular diseases which arise from rheumatism, or in 
the other arthropathies we have just enumerated. 

This uratic infiltration of cartilage is, then, the essential characteristic 
of articular gout ; and besides, there is here no other constant lesion of 
the cartilage. There is no segmentation of the fundamental substance, and 
there is no cell-proliferation, so that if the two changes are found existing 
simultaneously there is evidently a juxtaposition of the two diseases. They 
never undergo a transformation that permits of their being confounded. 1 





Fig. 13. 



Fig. 17. 

• 

Fig. 17.— Section perpendicular tn the articular surface : from a gouty cartilane. (After Cor- 
articular surface; v, n, group of cartilaginous cells infiltrated and 

poda; o, normal cartilaginous capsule, in contact with crystals formed in the fundamental robots 
the cartilage. (Magnified two hundred diameters.) 

Fig. 18.— A partly schematic representation of the dissolution at unite* encrusting a cartilaginous cell by 
the action of acetic acid. (After ComiL) c. oartflaginoufl capsules bristling with free crystals ; </, same cap- 
sule — the crystals are dissolved and other crystals of uric acid are forming : t". capsule whose membrane is 
visible, while the cell yet remains incrostatad ; c"', the whole cell clear, save only a small central nucleus. 

The articular lesions of gout maybe considered as the results of the | 
ence of a foreign substance in the interior of the tissues ; whereas the lesions 
of rheumatism, on the contrary, correspond to actual changes in the his 
gical elements. And thus, when a piece of cartilage removed from the arti- 
cular surface of a joint invaded by gout is treated with acetic acid, the crys- 
tals of urate of soda that infiltrate the cells are seen to dissolve, and these 
cells thereupon assume their normal appearance. 

"We think, then, that we have established, first, the unity of the various 
clinical forms of chronic articular rheumatism from a standpoint of morbid 
anatomy ; secondly, the existence of an unquestionable relationship between 
the changes in acute arthro-rheumatism and those in partial or chronic 
arthro rheumatism ; thirdly, a decided difference, always considered from 
an anatomical point of view, between the disease under discussion and 
the other diseases of joints. 

During this discussion, gentlemen, the question has no doubt presented 
itself to you : have the changes that we have just been describing anj 



1 Charcot and Cornil : Contributions a 1' Etude dee AlU'ratious Anatoiniqut ■ 
Goutte, in the Memoires de la Societo de Biologie. 1SG4. 



THE DISEASES OF OLD AGE. 115 

cific nature ? In other words, do they belong exclusively to the rheumatic 
diathesis ? 

Without adverting to anything which does not immediately concern 
chronic articular rheumatism, we are led to admit, even from a purely ana- 
tomical standpoint, the existence of sharply marked distinctions between 
the articular lesions this disease induces, and those which arise from gout, 
scrofula, and syphilis. 

It must, nevertheless, be acknowledged that the elementary lesions which 
collectively constitute arthritis deformans may likewise be encountered in 
cases where a rheumatic cause cannot possibly be adduced. Thus, in fun- 
gous arthritis, proliferation of the capsules and segmentation of the funda- 
mental tissue of the cartilage may here and there occur under the influence 
of an inflammatory action which, at a given moment, seizes upon various 
tissue^ The rarefaction and condensation of bone-tissue at the articular 
extremities, the formation of osteophytes and osseous swellings around the 
articular cartilages, are, as you know, met with in those joint-diseases for- 
eign to rheumatism. But it is the simultaneous change of the various 
parts in a joint, according to the method I have pointed out, and the ex- 
tent which these lesions may acquire without being complicated by suppu- 
ration, that constitute, in our eyes, the anatomical characteristic of this dis- 
ease. 

But here we are led to ask whether an irritation completely independent 
of the internal cause that induces rheumatism — a blow, a fall, for ex- 
ample — can produce the various changes of arthritis deformans in a joint. 

Certainly, gentlemen, we can recognize in these conditions all the 
lesions I have just enumerated ; but in such cases they are almost always 
confined to a single articulation. But even here are we not authorized in 
intervening a latent cause that decides the nature of the local disease ? 
Please to recall in this connection what occurs in subjects who are attacked 
with gout. * 

When articular affections are multiple — and this is most frequently the 
case — they always develop spontaneously, and seem to argue from this 
double claim a general predisposition of the economy. 

In such cases the influence of rheumatism should be adduced ; for in 
the present condition of science, we know of no other diathetic state to 
which we can attribute similar effects. 



116 CLINICAL LECTURES OK 



LECTUEE XIII. 

ACUTE ARTICULAR RHEUMATISM CONSIDERED ESPECIALLY IN ITS RE- 
LATIONS WITH CHRONIC ARTICULAR RHEUMATISM AND GOUT. 

4 

Summary. — A Succinct Description of Acute and Subacute Articular Rheumatism — 
Analogies with Chronic Rheumatism — Differences Separating it from Gout — Acute 
Rheumatism — Subacute Rheumatism. 

Multiple Arthropathies — Pain — Swelling — Redness — Temperature — Duration — 
Variations in the Disease. 

The General Constitutional Condition in Rheumatism — Fever — Irregular Prog- 
ress of the Disease — Relationship between Intensity of Febrile Movement and the 
Number of Joints Affected — Pulse — Secretions — Saliva — Urine— Intense Anaemia. 

Comparison between Acute Articular Rheumatism, Gout, and Subacute Articular 
Rheumatism — Pathological Blood-Conditions in Acute and Subacute Articular 
Rheumatism. 

Gentlemen: — I do not intend to give you a complete description of 
acute articular rheumatism ; such a study can only be pursued with ad- 
vantage in the ordinary hospitals. Nothing, in reality, is rarer among old 
persons than the acute form of Articular rheumatism ; nothing, on the 
other hand, more frequent than the chronic form of this disease, as we have 
already proved to you. 

Nevertheless, we cannot wholly overlook the history of acute articular 
rheumatism. We wish, in short, to maintain in the domain of the clinic 
the comparison we have established between these two dif ben anato- 

mically considered ; and in thus taking this new point of view, we shall 
again establish the fact that not only do analogies exist between them, but 
that there is actual identity in certain of their points. In a word, we 
to complete the demonstration of the view we espouse, namely : that this 
is not a question of two fundamentally distinct diseases, such as certain 
authors try to demonstrate, but only of two different manifestations of one 
and the same diathesis ; and you will easily recognize the salient points 
of resemblance uniting them, in spite of the diversities that result from the 
slow or the acute reaction of the organism in its symptomatic expression of 
disease. 

But, on the other hand, we shall arrive at a conclusion just the rev 
concerning the relationship of rheumatism to gout ; we shall show you that if 
certain appearances sometimes bring these two diseases in proximity, this 
occurs only in very exceptional cases ; and that these two d n al- 

most always be clearly distinguished (thanks to the rules for diag i 
which will be given farther on). 

I shall now give you a concise description of acute articular rheumr.' 
wherein we shall be careful to dwell only upon the fundamental character- 
istics. 



THE DISEASES OF OLD AGE. 117 



I. — Description of Acute Aeticulak Rheumatism. 

We here find ourselves confronted by the two forms whose existence has 
already been pointed out : on the one hand, acute articular rheumatism, or 
the rheumatic fever of English writers ; and on the other, subacute articular 
rheumatism (Garrod, Copland), or capsular rheumatism (MacLeod). Here 
there is a transition form, as we have already remarked, the characteristics 
whereof will later on be the subject of our study. At present we shall de- 
vote our attention to rheumatic fever. 

The most frequently multiple arthropathies which we already know from 
an anatomical standpoint, and which we shall soon study under a clin- 
ical aspect, are far from exclusively constituting acute articular rheuma- 
tism. To them is joined a collective reaction, expressed by a most charac- 
teristic general condition of body, by a distinctly marked change in the 
constituents of the blood (increase in the amount of fibrin and diminution 
of the red blood-corpuscles), and by the frequent, we might almost say 
habitual, coexistence of certain visceral diseases. Endocarditis and peri- 
carditis, for example, constitute one of the most fundamental occurrences 
in acute articular rheumatism ; and this characteristic contributes, in great 
measure, to our regarding this affection as a general disease, or at least as 
one having no definite seat, and not simply as a collection of arthritises 
more or less independent of one another. 

"We shall arrive at the same conclusion by a study of the development 
of the disease among the etiological conditions that may give rise to it, 
among which heredity, as you well know, plays so manifest a part. 

These, gentlemen, are the most general characteristics of rheumatic 
fever. Now, however, we must enter into some details bearing upon each 
of the points we have just described. 

A. — Arthropathies in Acute Articular Rheumatism. 

The characteristics of these local lesions are already known to you ; I 
shall therefore confine myself to the elucidation of the analogies and the 
differences which approximate or distinguish them from gouty diseases of 
joints. We shall first study them separately, and later on regard them col- 
lectively. 

First. — Pain. — This is pre-eminently nocturnal ; its intensity is much 
less than in gout, but it is accompanied by muscular cramps, as in the case 
of the latter disease. 

Second. — Swelling. — Tumefaction especially occurs in case of joints 
near the surface ; it may have its seat in the adjacent cellular tissue, or re- 
sult from distention of the synovial pouch by a serous or sero-fibrinous ex- 
udation. Contrary to what occurs in gout, there is no accompanying 
•local oedema rendering it capable of pitting on pressure of the finger ; 
Garrod, however, has sometimes seen this symptom occurring in cachectic 
individuals. There is no desquamation when the swelling subsides. 

Third. — Redness. — There is an erysipelatous appearance. It is not so 
strongly marked as in gout, and presents no ecchymoses ; moreover, the 
veins are less prominent. 

Fourth. — Temperature. — According to Bouillard and Neumann, 1 there 

1 Neumann : Ergebniss und Studien aus der medicinischen Klinik zu Bonn, p. 33. 
Leipzig, 1860. 



118 CLINICAL LECTURES ON 

is sometimes a difference of a degree Centigrade (nearly one and one-half, 
Fahrenheit) in the temperature of the affected locality and the surround- 
ing parts which do not partake of the heat resulting from the pathological 
activity. 

Fifth. — Duration. — Each one of these cases of arthritis lasts, according 
to Budd, 1 about from three to fifteen days. 

Let us now consider articular affections in their mutual relationships. 

Generally, several joints are attacked at the same time. A rheumatism 
mono-articular from the commencement probably does not exist ; when it 
is secondary, it is rheumatism located in a single joint. AVe will admit, 
however, that rheumatism may be partial ; that is to say, it inay have its 
seat in a small number of joints, in contradistinction to that which is 
general or poly-articular. In acute gout, you know, the disease is rarely 
seen as a general one from the beginning. 

As for its mode of invasion, there are characteristics that sharply differ- 
entiate rheumatism from gout. According to the research lessor 
Monneret, 2 when rheumatism is mono-articular, it almost never affects the 
great toe ; besides, the disease simultaneously invades the upper and lower 
extremities. In the majority of cases the knee, wrist, elbow, and instep 
are its places of election. Rarely are the smaller joints affected, except in 
the case of subacute rheumatism. 

According to Budd and Professor Monneret, it is the tibio-tarsal articu- 
lation that is most frequently the first to softer invasion. 

Rheumatic arthritis is often developed symmetrically upon both a 
but too much importance must not be accorded to this occurrence, since 
it is nearly a common characteristic of all diathetic arthropathies. 

Sometimes the abrupt disappearance of articular symptoms coincides 
with the sudden development of a visceral affection. But this is the ex- 
ception rather than the rule ; in any case, here is no experimental proof 
of a retrocession of the disease induced by external causes, as we have seen 
was the case in gout. 

Finally, one of the most essential clinical characteristics of this dia 
is its excessive instability, permitting it to dart from one articulation to 
another, and frequently to change its seat during the course of the malady. 



B. — TJie General — Constitutional — Condition in Acute Articular Rheumatism. 

Here the fundamental occurrence is fever : and, indeed, febrile reaction, 
manifested by a more or less marked rise in the general temperature, is 
never wholly wanting during the course of acute articular rheumatism. 

The heat of internal parts may exceed 40° C. (104 e Fahr. ), but it usually 
remains between 39° and 40° 0. (102° and 104° Fahr.), according to Wun- 
derlich, Hardy, and Sidney Ringer. 3 

The febrile movement assumes the continued type, with exacerbations 
and remissions which are generally very distinctly marked. The ther- 
mometry curves are here very irregular, and, according to Wunderlich, 
fail to furnish us with any exact information relative to the progress of the 

'Tweedie'a Library of Medicine, Art. Rheumatism. Vol. v., p. 191. 
8 Monneret : These de Concours pour le rrofessorat, p. 51. I B 
3 Aitken: Science and Practice of Medicine. Vol. ii. Rej 
Medicine. Vol. i., p. 890. 



THE DISEASES OF OLD AGE. 119 

disease ; but what is most frequently observed is the maximum tempera- 
ture during the day, and the minimum during the night. 1 

This disease, then, does not progress according to any regular type, it 
presents no cyclic course ; there are no stages succeeding one another at 
definite intervals, as in pneumonia or the eruptive fevers ; we do not have 
a severe chill marking the onset of the malady ; the disease is generally 
made up of the progressive increase in the intensity of its phenomena — an 
imperceptible transition conducting us from its initial stage to its climax 
and decline. And, indeed, the termination is not an abrupt one — there is 
no rapid defervescence ; it occurs slowly and progressively, unless in a few 
exceptional cases, where the temperature falls below the normal standard. 3 
Lastly, relapses are oftener the rule than the exception in this disease. 

We have yet to discuss a question that has been variously answered by 
different authors. Is the fever subordinate to the disease of the joint? 
Or is it, on the other hand, independent of any local lesion ? 

Certain it is that fever often persists after the arthropathy has entirely 
disappeared ; but in such cases it is almost always maintained by some 
latent visceral disease, as, for example, an endocarditis or a pericarditis. 

Again, fever may precede symptoms developed on the part of the joints ; 
but here, also, it is often (we do not say always) induced by one of those 
visceral affections which sometimes set in before the articular manifesta- 
tions of rheumatism. 

Still, the febrile movement is often of great intensity when there is a 
small number of affected joints. Here is an unknown element that escapes 
us, seeming to justify the opinion of Graves, Todd, and Fuller, who regard 
fever in rheumatism as primary, and not secondary. 

We have now regarded rheumatic fever from a general standpoint. 
Let us consider it, then, in detail, along with the accessory phenomena of 
the febrile state. 

The pulse, whose frequence, according to Louis, 3 does not exceed ninety 
or one hundred pulsations per minute, presents special characters not met 
with, in other febrile diseases, to the same extent. The artery is of large 
volume, as in certain cases of anaemia, according to Monneret, Todd, and 
Fuller. 4 The sphygmographic tracings express this wonderfully well ; 
they show an enormous amplitude, 5 and quite a pronounced dicrotism of 
the pulse — indeed, a remarkable resemblance to the pulse of aortic insuf- 
ficiency. It is understood, of course, that, when cardiac disease super- 
venes, these characteristics undergo profound change. 

The secretions in acute rheumatism are deserving of special attention. 
Perspiration stands in the first rank here, and is remarkable, in general, for 
its abundance and extreme acidity, especially about the affected joints. 8 
The sudamina contain a fluid whose reaction is manifestly acid, and this 
property of rheumatic perspiration resists alkaline treatment — even in very 
large doses — during quite a long time. To these acid exhalations must 
undoubtedly be ascribed the sourish smell given off from rheumatic pa- 
tients. But we cannot affirm with precision what principle, from a chem- 
ical point of view, determines this reaction ; it has been attributed to lactic 

1 Wunderlich : Pathol, und Therapie. Vol. iv., p. 621. 

2 Hardy : Theses de Paris. 1859. 

3 Louis : Recherches Anatomiques, Pathologiques et Therapeutiques sur la Fievre 
Typhoide. Vol. i., p. 443. 1841. 

4 Monneret : Loc. cit., p. 53. 

5 Marey : Physiologie Medicale de la Circulation du Sang, p. 545. 

6 Williams : Principles of Medicine. Third edition, p. 194. London, 1856. 



120 CLINICAL LECTURES ON 

acid, but the proof of this is insufficient. Simon states that, in the course 
of acute articular rheumatism, there is acetic acid in the sudatory secre- 
tion ; and this, according to the same writer, does not occur in the normal 
state of affairs. But Schottin has shown that, even in a condition of health, 
sweat not only contains acetic acid, but also butyric acid and formic acid. ' 

Saliva, according to Fuller, 3 becomes acid in acute rheumatism ; and 
besides, all the fluids of the economy are, according to this author, remark- 
able on account of their distinctly acid reaction ; the serous effusions into 
the pericardium and into the joints are also of an acid reaction. In a few 
cases I have remarked this latter occurrence, but only in exceptional c 
and this also occurs in gout. Let me add that the intra-articular fluids, 
sometimes acid, are also, in some instances, alkaline. 

The condition of the urine is particularly deserving of attention, since 
here we find a distinctive difference between rheumatism and gout. Upon 
immediate inspection, the urine is scanty and very highly colored ; upon 
cooling, it throws down a copious deposit of urates of a brick-red color. 

Upon analysis, there is a marked diminution in the watery part (ex- 
plained by the abundant perspiration), and an increase in the solid ingre- 
dients. Urea and coloring matter are especially found in large proportion ; 
the occurrence of the latter probably corresponds to a destruction of the 
blood-globules greater than that in any other phlegmasia. 

The percentage of uric acid is increased, it being found in the propor- 
tion of 0.85 to the litre, according to Parkes, 3 and 0.75 according to Gar- 
rod.* Here is offered another point of contrast with gout. 

There is a diminution in the proportion of chlorides, not so great, how- 
ever, as in pneumonia ; and, lastly, there is well-marked acidity, though 
nothing proves that this arises from the presence of an excess of lactic arid. 

A final characteristic of the general bodily condition in acute articular 
rheumatism is the intense ameinia developed in a few days after the com- 
mencement of the disease, even in those cases where no recourse has 
had to the antiphlogistic method of treatment. There is certainly a similar 
result in phlegmasia) (on account of the destruction of the blood-corpnscles), 
but to a very much less extent. Todd. OTerral and Fuller in England, 
Canstatt in Germany, and Monneret and Piorry in Trance, have dwell 
great insistence upon this point. In acute gout the condition of things is 
quite opposed to these phenomena, and we cannot help seeing therein a 
further difference between that malady and the one under present dis- 
cussion. 



II. — Comparison between Acute Articular Pheoiatism, Gout and Sub- 
acute Rheumatism. 

Following this summary description of acute articular rheumatism, we 
are prepared to point out the differences and the analogies which i: 
either with gout or with subacute rheumatism. 

First. — Concerning acute gout, there is only one analog}- to b 
out here ; this is the irregular and paroxysmal progress of the disease. 
Everywhere else we discover nothing but differen 

Thus, in gout, the temperature is lower (so far as can possibly 1 

'Donders: Physiol. Vol. i., p. 450. e Fuller: 

3 Parkes: On Urine, p. 896". London. 1S00. 

4 13.12 gr. in 2.1135 pints (Parkes) ; and 11.58 gT. in 2.1135 pi;.; — L. II. IL 



THE DISEASES OF OLD AGE. 121 

firmed in the present state of our knowledge), and fever is not so intense ; 
it seems to be more rigorously subordinate to the number of joints affected, 
and only assumes a truly high degree in general gout. 

The pulse no longer presents the special characteristic that we found to 
prevail in rheumatism. 

Perspiration is much less copious, and does not possess the acidity we 
have mentioned. 

The urine differs from that described in rheumatism, although it is the 
same in appearance ; but when we make an analysis of it, far from being 
any excess, we rather find, in gouty subjects, a diminution in the quantity 
of uric acid. 

Finally, anaemia is never marked from the onset in cases of acute gout. 

Second. — Again, subacute articular rheumatism occurs with the char- 
acters of the acute form ; but the febrile movement is less intense, as are 
all the accompanying phenomena ; the anaemia, however, being quite as 
marked as in acute articular rheumatism. On the other hand, the articular 
affections are more permanent, contrasting thus with the extreme un- 
settledness or mobility of the local manifestations of acute articular rheu- 
matism. Lastly, we may draw a distinction between these two forms of 
rheumatism in respect to their duration ; this is from six weeks to two 
months, according to MacLeod, in the subacute variety ; while in acute 
rheumatism, the duration has been variously estimated, although the figures 
are always much smaller than those we have just enumerated ; indeed, 
Professor Bouillard puts it at from eight to fifteen days. Legroux at one- 
and-twenty ; Chomel and Requin at twenty-eight ; and, according to Lebert, 
it varies in length with the metjiod of treatment, and may even extend over 
twenty-eight or thirty-five days. 



ILT. — Pathological Conditions of the Blood in Acute and Subacute Ar- 
ticular Rheumatism. 

The composition of the blood in articular rheumatism diners consider- 
ably from what exists in cases of acute gout, and this is unquestionably one 
of the most important distinctions which differentiate these two diseases. 

The clot of blood drawn from one who has acute articular rheumatism 
is, you know, resistant and retracted, resembling the buffy coat of pleu- 
risy, or, as Sydenham somewhat familiarly puts it, they are alike as two eggs. 

The investigations of Nasse, Simon, Andral and Gravarret, Becquerel and 
Rodier, furnish the explanation of this occurrence ; they found a consider- 
able increase in the proportion of fibrin which might reach seven or eight 
parts in one thousand, instead of three, the normal standard. At the same 
time there is a considerable diminution of the red blood-corpuscles. In 
this respect the composition of the blood in acute articular rheumatism 
may be regarded as the type of inflammatory blood, and differs essentially 
in its composition from that of the blood of gouty subjects. 

Finally, let me add, that in those suffering from rheumatism the serum 
of the blood is alkaline, the proportion of urea is normal, and no excess in 
uric acid is found. This fact, which to-day is beyond all dispute, possesses 
a degree of importance impossible to be exaggerated. 

But does not the blood in acute articular rheumatism present a few 
special characters belonging to it exclusively ? Does it not contain some 
pathological product, some material that is foreign to the normal constitu- 
tion, explaining why acute articular rheumatism differs in so many ways 



12S CLINICAL LECTTEES ON 

from ordinary phlegmasia, which are nevertheless accompanied by the 
same kind of changes in the composition of the blood ? 

Many analogies are adduced in favor of such an hypothesis ; but as yet 
they do not rest upon any positive fact. 

In the last century, Van Swieten, Baynard, 1 and many other physicians 
made rheumatism dependent upon a particular acrimony of the blood, a 
retention of acids and salts that should have been eliminated through the 
kidneys. An hypothesis more in keeping with the data of modern chem- 
istry has recently been advanced in England. It is supposed that lactic 
acid — the normal product of the disassimilation of fibrous tissue — is formed 
in excess and gives rise to all the phenomena we have just described. 
This opinion is upheld by Prout, Williams, Todd, and Fuller ; but it does 
not stand on a firm basis of fact. Yet Richardson, after having injected 
lactic acid into the veins of dogs, found articular lesions and disease of 
the heart in the animals. His experiments, however, were repeated in Ger- 
many, and it was stated that cardiac disease in the canine species ? 
very great frequence, apart from any artificial interference. In this way it 
seems well established that the endocardial lesions existed previously ; 
and as for the articular lesions, you must remember that they an 
in a large number of cases, by various kinds of poisoning. 

One circumstance deserves to have attention called to it in closing this 
rapid sketch. Inopexia — excessive coagulability of fibrin, independent of 
all excess in its amount — is present in the highest degree in acute articular 
rheumatism ; hence the exceeding frequence of vascular thromboses and 
fibrinous cardiac vegetations in the disc: 

On the other hand, in many grave cases we notice an entirely opposite 
condition. We then find at th< Hem the blood to be fluid and 

black; 2 it no longer reddens from contact with the air, and it i- 
especially that the fluid exudations into serous cavities have a markedly 
acid reaction, as we have several times attested. 

Finally, let me recall to you that, in many individuals, rheumatism seems 
to be allied with the hemorrhagic diathesi 

To summarize, we think we have shown that articular rheumatism, 
in all the various forms it may assume, constitutes one and I mor- 

bid species, a species essentially distinct from gout. Acute, chroni 
subacute rheumatism, the latter serving as a transition between ti 
extremes, are actually but one and the same disease. "We have endett 
to prove this by a study of the articular lesions and general char 
of the disease ; we shall find a new proof in the study of the 
which will form the subject of our next lecture. 

baynard: Philosophical Trans, (abridged). Vol. iiL, p 

2 Yogel: Virchow's Handbuch der sp. Path, uud Therapie. Vol. i., p. 



THE DISEASES OF OLD AGE. 123 



LECTUEE XIV. 

VISCERAL AFFECTIONS IN ACUTE AND CHRONIC ARTICULAR RHEUMA- 
TISM. 

Summary. — Comparison of the Visceral Diseases of Gout, and those of Acute or 
Chronic Rheumatism — Tardy Development of Visceral Affections in Gout ; their 
Early Development in Acute Rheumatism — These Lesions manifested still later on 
in Chronic Rheumatism — Difference in the Nature of Visceral Lesions in Rheuma- 
tism and Gout — Cardiac Disease in Rheumatism — Rheumatic Pericarditis — Rheu- 
matic Endocarditis — Modifications in the History of this Disease, Caused by the 
Progress of Modern Histology — Structure of the Internal Membrane of the Heart — 
Inflammatory Lesions of Endocarditis — Principally Located upon the Valves — 
Description of the Pathological Process — Tumefaction of the Endocardium ; Vas- 
cularization of this Membrane — Result of this Pathological Condition — Capillary 
Embolism — Lesions of Canalization — Typhoid State — l hronio Stage of the Dis- 
ease — Multiple Affectious the Consequences of these Lesions — Ischasmia, Local- 
ized Gangrene — Ecchymotic Spots — Cerebral Softening — Fibrinous Deposits in 
the Spleen, Liver, and Kidney — Various Complications of Acute Articular Rheu- 
matism — Cardiac Lesions may likewise occur in Subacute and Chronic Rheuma- 
tism — Lesions of the Respiratory System — Pleurisy, Pneumonia, and Pulmonary 
Congestion —Asthma and Emphysema — Pulmonary Phthisis — Lesions of the Uri- 
nary Apparatus — Nephritis — Albuminuria — Cystitis — Lesions of the Nervous Sys- 
tem — Cerebral Diseases — Medullary Affections — Abarticular Lesions of Various 
Kinds — Muscular Pains — Neuralgias — Derangements of the Visual Apparatus — Cu- 
taneous Diseases, Eczema, Psoriasis, Prurigo, Lichen, etc. 

Gentlemen : — Today we shall consider the abarticular affections of 
rheumatism. "We shall at first endeavor to compare them with the changes 
which gout induces on the part of our internal organs ; and then we shall 
ask ourselves whether the visceral lesions of acute rheumatism are met with, 
possessing the same characteristics, in the chronic forms of the disease. 

During the course of an attack of acute gout, derangements of a purely 
functional nature are, for a long while, the sole indications that the viscera 
are suffering ; they leave no material impress behind them, and it is only 
when incessant return of the ' attacks begins to clothe the malady with a 
chronic form, that we see those permanent changes develop which daily 
become graver and graver. 

In articular rheumatism it may be said that things follow a nearly in- 
verse order. Indeed, one of the prime characteristics of this disease (at 
least in the acute form) is an unusually early development of certain vis- 
ceral lesions (endocarditis, pericarditis, etc.), which frequently manifest 
themselves at the first attacks — indeed, scarcely waiting until the disease 
has passed through its initial stage before they are quite distinctly marked. 
There is no longer, in these cases, any question of purely functional de- 
rangements, but of permanent lesions modifying the texture of organs, and 
almost always leaving behind them indelible traces of their occurrence. 

Primary chronic rheumatism differs from the acute form in this regard. 
The existence of visceral disease here is so unusual that several authors 
have called it in question, and it may be said that the more the disease 



124: CLINICAL LECTUEES OX 

tends to assume the chronic form, the rarer it is to see similar lesions de- 
veloped during its progress. 

Another fact to be emphasized here is that the visceral affections of 
rheumatism are only analogous to those of gout in a gross aspect ; in reality, 
the lesions are essentially different. 

Thus, the cardiac derangements — at first purely functional — that may 
supervene in cases of gout, are localized in the muscular fibre, "when they 
become transformed into permanent lesions ; we then find a condition of 
fatty degeneration. 

In acute articular rheumatism, on the contrary, the cardiac diseases are 
inflammatory lesions expending their potency upon the endocardium and 
pericardium, only attacking the muscular tissue of the organ secondarily. 
The organic changes they so often leave behind them are the result of this 
inflammatory action. It is well known that, in nearly one-half the cases 
where there are permanent lesions of the auriculo-ventricular valves, acute 
articular rheumatism is the acknowledged cause. 

Later on in the course of these lectures we shall dwell more particu- 
larly upon the cardiopathies, which are, to a certain extent, an integral part 
of acute articular rheumatism. They may be considered as one of the 
most characteristic features of this disease ; the frequence in such cases 
being, in fact, so great, that when acute endocarditis or pericarditis is seen 
coexisting with an otherwise ill-defined articular affection, we are in the 
great majority of cases justified in ascribing the train of occurrences to 
rheumatism. 

We shall, therefore, chiefly concentrate our attention upon those car- 
diac lesions whose recognition is of such great importance ; tlie other vis- 
ceral diseases of rheumatism are of much less interest from the special 
standpoint we have assumed ; nevertheless, we shall say a few words con- 
cerning them. 



I. — Endocarditis and Pericarditis in Acute Articular Rheumatism. 

Rheumatic pericarditis is a disease which has been known for a long 
time ; it can certainly be asserted that, to-day, all the points in its history 
are familiar to us. \Ve know that it is an inflammation of the serous mem- 
brane enveloping the heart, and that this inflammation generally results 
in the formation of a sero-fibrinous exudation which, in a few exceptional 
cases, may assume a hemorrhagic or purulent character. 

Farther on we shall point out the symptoms which, collectively, reveal 
the existence of this condition, and the particular circumstances in which it 
develops. 

The history of endocarditis has, on the other hand, been singularly 
changed by the progress of histological study, and rheumatic endocarditis 
has particularly taken part in the transformation. 

At an epoch not yet very remote, the endocardium was represented 
serous membrane, and the lesions it presented were thought to possess the 
characteristics of an inflammation of a serous membrane. In hifl 
carditis, it is well known that Kreisig described the secretion of plastic lymph 
as one of the principal characteristics of the disease; and it is also known 
that in the remarkable study upon endocarditis, by Professor Bouillard, this 
author dwelt with emphasis upon the intense redness presented by the in- 
ternal membrane of the heart. 

At present we are aware that, in certain respects, these views are lack- 



THE DISEASES OF OLD AGE. 



125 



ing in exactitude. The endocardium is not identical in structure with se- 
rous membranes, and does not inflame in the same manner. But it was 
an exaggeration in the reverse direction when men went so far as to deny 
the existence of the endocardium. To simple fibrinous deposits some have 
ascribed all the lesions which occur in this disease (Simon). This is an 
ultra-development of an idea which Laennec had previously advanced. 

There is a certain amount of truth in both these opinions. There is 
endocarditis, and the internal membrane of the heart can become inflamed; 
but there is no plastic exudation. On the other hand, the formation of 
clots in the interior of the cavities of the heart plays an important part in 
the disease ; but this occurrence is always secondary, and ought never to 
usurp the first place. 

Let us first examine the histological structure of the internal cardiac 
membrane : we shall then be better prepared to understand the changes of 
which it may be the seat. 

The endocardium is essentially composed of a very thin layer of connec- 
tive tissue, containing a certain number of elastic fibres, and covered with 
pavement-epithelium. According to Luschka, the endocardium is contin- 
uous with all the tunics of the vessels, but the majority of writers state that 
it is only continuous with their internal membrane (tunica intima). 

The endocardium has no vessels of its own ; but upon the cardiac parie- 
tes the subjacent capillaries are very close, on account of its great thinness. 
It is wholly different in the neighborhood of the valves ; here the investing 
membrane is thicker — a few vessels, according to Luschka, being found 
ramifying between the two lips of the mitral valve ; but these never exist 
in the sigmoid valves in their normal state. 

Now, it is upon the valves — that is to say, upon the very thickest portions 
of the endocardium, upon the portions farthest removed from the blood- 
vessels — that inflammatory lesions are preferably located ; they commence, 
too, upon the external surface. 

In what, then, does the pathological process consist ? 

In the acute stage the morbid action commences by a tumefaction of 
the affected portion ; small papillary elevations are formed, made up of pre- 
existing elements which have sensibly increased in 
size, and also of cells of new-formation along with 
embryo-plastic cells. The whole papillary elevation 
is filled with a fluid whose reaction is similar to that 
of mucus. This is the first period of the disease. 

In the second stage the elevations sometimes 
acquire a permanent organization ; and again their 
extremities are ulcerated, this lesion being the con- 
sequence of a granular degeneration that must not 
be confounded with fatty metamorphosis. These 
little ulcers have truncated apices. 

Later on, the reddened and swollen point be- 
comes covered with a layer of fibrin more or less 
thick, according to the case. And, as you know, 
inopexia (a tendency to coagulation of the blood) 
is an habitual result of rheumatism, as well as of 
the puerperal state and certain peculiar cachexia?. 

Valvular vegetations of the endocardium are the result, then, of inflam- 
mation of the tissue itself and of a secondary deposit of a fibrinous layer. 

But, wnile this action is progressing, the vessels are developing. In the 
mitral valve, where they already exist, they become more apparent ; and in 




Fig. 19.— Acute endocardi- 
tis : section of the mitral valve. 
a, superior layer of the endo- 
cardium ; a', inferior layer ; b, 
middle layer, whose vessels 
show a marked degree of hy- 
peremia ; c, efflorescence (gran- 
ulation) of the superior layer 
of the endocardium ; ri, fibrin- 
ous deposit (Yin)- (Taken from 
Rindfleisch : Lehrb. der pa- 
thol. Gewebelehre, p. 186. 
Leipzig, 1866.) 



126 CLINICAL LECTURES ON 

the sigmoid or semilunar valves they are of completely new formation, 
or at least neighboring capillaries send out prolongations into the parts 
destitute of vessels, as occurs in the cornea when that becomes the seat 
of inflammation ; and in this way arborescent vascularity may be found ap- 
pearing about lesions which have invaded the cardiac orifices. ' 

It is very important to study the consequences of this pathological con- 
dition. First, however, let us see what are its immediate results. 

In some instances the changes go no farther than this ; and then there 
are no lesions of canalization. Sometimes the fibrinous deposit softens, 
breaks down, and the detritus formed gives rise to capillary embohsm. 
This is an essentially clinical side of the question and a wholly new aspect 
of it, whatever may be said to the contrary. 

Again, and finally, the ulceration deepens, and then we have valvular 
perforations which give rise to the most diverse lesions of canalization ; the 
union of several of these openings may lead to the detachment of a frag- 
ment of the valve, and thus arises an embolism of greater or less size. Do 
not forget that valvular aneurisms are sometimes produced, located either 
at the mitral orifice or at the sigmoid valves. 

In some cases the process undergoes a modification from causes un- 
known to us. Then pus may be formed, but this is a rare occurrence ; we 
oftener witness the development of deleterious material which comes from 
other parts and infects the mass of blood, giving rise to typhoid symptoms. 
In the majority of such cases we say that it is an instance of ulcerative en- 
docarditis ; but, properly speaking, the ulcerative form of endocarditis is 
not necessarily accompanied by septicemia. 

The ulterior consequences of endocarditis are met with in the chronic 
stage of the disease. The phlegmasic activity spreads and changes its 
nature ; the whole valve becomes indurated, giving rise to a shrinking and 
toughening of it ; hence, insiuiiciency follows. At other times adhi 
form between the diseased valve and the margins of the orifice, sometimes 
inducing an insufficiency, sometimes, on the contrary, a stenosis. 

There are, occasionally, compensatory lesions, as has I -factorily 

proved by Jacks ; contraction of one of the semilunar valvt - mple, 

left a void which, in some cases, was filled in by an elongation of the other 
two ; and in this way the mechanical portion of the lesion may be oared. 
I have, myself, met with unquestionable cases of this sort in the cadaver. 

These are the elementary lesions of endocarditis. We shall not d 
in this place upon the appearance presented to the naked eye : it is well 
known that these lesions occupy preferably the left heart and its aurieulo- 
ventricular orifice, and that upon the mitral valve they especially invade the 
auricular surface and the parts which are in contact. At the semilunar 
valves these pathological depositions readily assume the form of a 1 1 
of vegetations. What is of the greatest importance, however, to adduce here, 
is that there may often be no lesions of canalization. Frequently there is 
nothing produced except simple stigmata, which give rise to no appro 
functional derangement during life, and are only discoverable a: 
autopsy. 2 This occurs more frequently than is generally supposed ; and, 
while taking into account these rudimentary lesions, the proportion of co- 
incidences between diseases of the heart and rheumatism is mad, 



1 Ball : Du Rheumatisme Visceral. These de Concours pour rAgTc'g-ation. 

i o™ Charcot : Comptes Rendus de la Societe de Biologie. Third » 
1862. 



THE DISEASES OF OLD AGE. 127 

great. It is in the chronic form especially that it is important to note this 
j)oint, as we shall presently see. 

But, first, I wish to say a few words concerning the multiple affections 
arising from endocarditis, for this is not only one of the most original sides 
of the question, but one of the newest conquests of science. 

At the present time we know that movable bodies may be detached from 
the diseased orifices, either at the expense of the fibrinous deposits, or the 
valves themselves, and, once thrown into the torrent of the circulation, they 
produce various symptoms in remote parts. 

"We must here distinguish between the results produced by displace- 
ments of large concretions and those arising frorn the transportation of 
almost molecular fragments. 

First. — Arterial emboli, properly so called, may obstruct the circulation 
in vessels of the first order ; the femoral and even the external iliac have 
both become suddenly impervious to the circulatory current on account of 
the presence of a large sized clot from the heart. 

When the arteries in the limbs are thus plugged, the result is generally an 
ischsemia terminating usually in gangrene. Watson, Tufnell, and several 
other authors, have reported instances of this in cases of rheumatic endocar- 
ditis. 1 

Second. — Capillary emboli — of infinitely greater frequence — may occur 
in nearly all the organs, and give rise to lesions of the most different kinds. 

A. — When the cutaneous capillaries are obstructed, more or less exten- 
sive ecchymotic spots are produced. 

B. — When the encephalic vessels are the seat of embolism, the result is 
softening, sometimes red, sometimes white, which is one of the most fre- 
quent causes of hemiplegia in those who have not yet attained an advanced 
age. When the obstructed artery has a large calibre, instantaneous hemi- 
plegia is sometimes the consequence, and secondary softening almost always 
occurs. Kirkes has reported an extremely remarkable case of this kind. 

Analogous symptoms are sometimes developed, when the principal arte- 
ries of the brain are found perfectly permeable after death. We observe, 
first, the appearance of all the symptoms of softening which occur in their 
usual order of progression ; but after death we can find no lesion in the 
vascular canals. This anomaly may be explained in two ways. Actual ob- 
struction has occurred in vessels of a large calibre ; but the clot being re- 
absorbed, the artery has again become permeable, while the softening con- 
sequent upon the plugging has perished. On the other hand, it may be 
admitted that, very small vessels being thus obstructed, a cerebral disease 
has developed without the existence of any obstacle in the great encephalic 
circulation. 

I have myself seen a case of this kind. The patient having first been 
in Trousseau's service, this eminent clinician admitted the existence of a 
cerebral embolism, following a valvular lesion of the heart. In this woman, 
who died later, in my ward, I found at the autopsy that there existed an 
old endocarditis with vegetations upon the mitral valve ; but that no ob- 
struction in the arteries of the base of the brain was found. 2 Cases of this 
kind may be explained upon the ground of reabsorption of the thrombus ; 

1 Watson : Principles and Practice of Physic. Fourth edition. Yol. ii., p. 314. 
Tufnell : Dublin Quarterly Journal. Vol. xv. , p. 371. Goodf ellow : Transactions of 
the Medico-Chirurg. Society of London. Second series. Vol. xxviii. 18G2. 

2 Trousseau : Clinique Medicale de l'Hotel-Dieu. Vol. ii., p. o87. Bouchard : 
Comptes Rendus de la Societe de Biologie, p. 111. 1S64. 



128 CLINICAL LECTUEES ON 

this reabsorption is sometimes complete at the time of making the air 

but in other cases slight vestiges of the obstructing clot are still found, 

which thus enable us to discover its nature to a certain extent. 

This form of lesion is so frequent after rheumatic cardiopat: 
Lancereaux in his thesis attributes more than half the pathological CM 
collected to this cause. 1 

C. — The spleen very frequently becomes the seat of capillary eml>oli 
ing rise to infarctions having a cone-like form. I rd the 

hilum, after the well-known manner of distribution of the in thi-j 

organ. 

We ourselves had an opportunity to observe an ii. 
this lesion manifested itself in consequence of a rb< umatic affection i 
heart. The patient whs a man, twenty-four y< 
tacked with acute articular rheumatism and then witi. 
During life he had a double "rasping " murmur at 1 1 
complained of intense pain in the region of t .. which 

acquired considerable size, lb died with the orduD 
disease. 

At the autopsy fibrinous vegetation 
semilunar valves, and two fibrinous <i 
considerable size, the other a little Email 

D. — The kidneys may also under, 
knowing their origin, however, h 

tion of them under the nam* • ;. and 

7, of Plate Foi the atlas of the M Trail 
tise on Diseases of the Kidneys— are axampli 
patients suffering from heart 

Capillary embolism of the kid:. 

accurately described in the tl lann. 1 I 

in a fatty degeneration which OCCUR arou: 
is, later on, followed by a llatt. : : ix. 

E.— The liver itself has no immunity fi 
organ is affected only in rare ii - 

F. — To these lesions arising fi 
add the septicemic phenomena which 
cardiopathies. We then see the sym] 

the deep jaundice, and th. h is a»so< 

with acute articular rheumatism. 1 



H — Endocarditis and Pericarditis i - te and I 

Rm 

Gentlemen, now that we have thus traced tie 
and pericarditis in acute rheumatism, we thai] 
these complications do not exclusively 

1 De la Thrombose el de l' Emboli C 

■ Dea Lesions Visoeralea Suites d'Embolie 

° \\ hen the right heart is the starting point I a mar have 

pulmonary emboli, sometimes OMI || instant d 

ported by Goddard-Uo^vrs. It 1 

carditis, in which the patient was suddenly seized, on i han attack 

of orthopnea, inducing death in the ] 

pulmonary artery was found plugged with a lar. • from ih«. 

heart.— The Lancet, p. 10. London, 1865, 



THE DISEASES OF OLD AGE. 129 

First, they are quite frequently met with in subacute rheumatism, in 
spite of the celebrated law of Professor Bouillard, at once so rigorous and 
so tyrannical a law, if thus I may be allowed to express myself. 

Endocarditis and pericarditis are undoubtedly more frequent in acute 
and poly-articular rheumatism. Valleix, Latham, Bamberger, and Fuller 
are in full accord, in this respect, with the French clinical savant. 

Nevertheless, cardiac complications are met with quite often in cases 
where a few joints only are affected, or where the febrile movement is not 
at all intense. West found this the case in children ; and Walshe, Ornie- 
rod, and Garrod affirm it for adults. If I may be allowed to offer my own 
experience in this connection, I have seen several cases of subacute rheu- 
matism, where an autopsy has been made, coinciding with disease of the 
heart. One of these cases is recorded in Dr. Ball's "These d'Agregation." 1 

But the question is to prove that these lesions may exist in chronic, 
in nodular rheumatism, properly so called. 

First. — It must be remembered that rheumatic endocarditis is very often 
a latent disease during life, but it almost always leaves behind it traces 
that can be recognized after death. Hence, one must not always expect 
to meet with palpable murmurs in patients suffering from chronic rheuma- 
tism, but pathological anatomy enables us to establish, in this respect, a 
bond of relationship between the acute and the chronic form of articular 
rheumatism, proving once more that there is but one and the same dis- 
ease, notwithstanding the diversity of its pathological manifestations. 

Cardiac lesions are quite frequently found in nodular rheumatism. A 
case of this kind has been described by Romberg in 1846. ' Two other 
cases are found in the thesis of Dr. Trastour and in mine, in a collection of 
forty-one observations. Since that time, attention having been drawn to 
the circumstance, cases have multiplied. A few years ago, Beau, in a clini- 
cal lecture demonstrated the coincidence of aortic stenosis in a young 
girl with nodular arthritis ; 3 and Dr. Ollivier, when in Professor Grisolle's 
service, observed a case where a man, twenty-three years old, presented the 
characteristic deformities of nodular rheumatism, and gave evidence of a 
change in the aortic semilunar valves. 

It is very often the case that these patients have had a previous attack 
of acute articular rheumatism ; but I have gathered quite a large number 
of observations in which endocarditis has developed in patients with chronic 
rheumatism when the disease has never taken the acute form. Two of 
these cases are found in the thesis of Dr. Ball. 4 

The first case was that of a concierge," a woman sixty years of age, 
whose right hand bore the characteristic deformities of chronic rheumatism. 
She ascribed this disease to the dampness of the lodge which she had oc- 
cupied so long. 

She came to the infirmary of the hospital for the first time on account of 
a right hemiplegia, and gave no evidences then of an}- cardiac implication ; 
after two months' treatment she went back to her dormitory. 

But the second time she came, there were evident signs of heart-trouble. 
The symptoms of the disease became rapidly worse, and death soon oc- 
curred. 



1 Du Rheumatisme Visceral, p. 64. 

1 Klinische Ergebnisse. Berlin, 1840. A similar case was described by Todd, in 1843. 
3 Gazette des Hopitaux. July 19, 1864. 4 Op. cit., p. 121 and following. 

s A concierge occupies a loge — a sort of box — at the door of buildiDgs where dwell 
manv families, and is door-keeper and janitor combined. — L. H. H. 

9 



130 CLINICAL LECTURES ON 

At the post-mortem examination there was found a general adhesv 
the pericardium to the heart, and thU lesion was evidently of for 

the pericardium could easily be removed from the subja me. The 

heart had attained an enormous size, and wrealh-like were seen 

upon the semilunar aortic, and the mitral valves, wht 
sented a remarkable degree of vascularity. 

In the second case the patient, eighty-four years old. died in the in- 
firmary of the Salpetriere, from cancer of the fa tins 
woman was found B dry arthritis of the should* 1 

heart was large, flaccid, and Loaded with fat ; an<i pes uxre 

palpable traces of an old end 

It thus seems evident to me, in view ol the fart- I presented, 

that we may meet with org onsoftb . iary 

chronic rheumatism. 

Second.— It is probable thai 
tism, for of nine autopsies I ma 
it in four. Indeed, we DOW ha 

Dr. Mauriac has reported i ■ ^ 

Menaces Hospital 

Let me give you an anah> 

A woman, seventy-on. l: suffered fro t 

articular rheumatism and puhn 
with intense dyspnoea and 

elicits a slight inoreaee in the ana • nesa, and on ausculta- 

tion we hear 

half of the sternum, where it mask- nial heart 

influence of appropriate n 
six weeks, after having 
lations that were already dianaa 

This case may be oompared to 
service at theSainte-Eu 
chronic articular rheumatism, .. 
sounds in the precordial region. 1 
long. The rheumatism in 
the pericarditis; and sube 
highest degree, all the ehar 

Since the period when my atl 
frequently m en oases ol pi ricarditi the exacerba 

arthropathies in : | with ehi 

stances I have just record, 
observations. 

To sum up. then, endocarditis and | c>ccur m 

some cases of chronic articular rheumatis] 

exhibit the same char* • absent in , umatiam. They 

occur preferably during the period . 
it somewhat approzhna 

diseases are, m general, of a less serious nature when 
a chrome articular rheumatism. 



1 Cornil : Momoiro sur 1, noe « Patbolojriquet du Kheamatiam« ArticuUire 

Chromque. Momoirea de la Soc! irth *x£.**L It. 18* 



THE DISEASES OF OLD AGE. 131 



LTI. — Some other Abarticular Diseases in Chronic Eheumatism. 

Cardiac affections are not the only visceral manifestations of the rheuma- 
tic diathesis. Let me remark, however, that it is important to observe that 
the other usual complications of acute articular rheumatism are more rarely 
met with in the chronic variety than endocarditis and pericarditis. But, 
on the other liand, we shall soon learn that certain affections accompany 
the chronic form that are almost wholly unknown to the acute, as one 
would naturally surmise. 

In this connection we shall rapidly review the principal systems of the 
economy. 

The Respiratory Apparatus. — Pleurisy occurs in subacute and chronic 
articular rheumatism, but it is much rarer than in the acute form. 

e pneumonia is a frequent complication of acute arthro-rheumatism ; 
I have never met with it in the chronic form. I have certainly seen some 
s of chronic pneumonia in rheumatic patients, but the latter were 
cachectic. 

Rheumatic pulmonary congestion, that dire condition rendering the pa- 
tient liable to sudden death, may be encountered in subacute or chronic 
rheumatism. Dr. Ball records a very remarkable case of this kind in his 
"Tb a -ation." ' 

Certain thoracic affections occur especially in chronic and ill-defined 
forms of articular rheumatism. . followed by emphysema, is as com- 

mon in this disease as in gout I have seen this complication twice in 
lip triere. 

The firai case was that of a woman, sixty years old, who for twenty-five 
i a washerwoman. 

Her asthma dated back ten years. At first the attacks were few and noc- 
turnal. At the time of recording the ease the paroxysms were so closely re- 
current, so commingled, that the patient passed the greater part of both day 
and night sitting on the bed, breathing with intense difficulty and distress. 

There were always sibilant rales that could be heard at a distance, and 
auscultation showed great feebleness of the vesicular murmur over the entire 
surface of both lungs. The expectoration was scanty. 

This woman never had been attacked with acute general articular 
rheumatism ; but several times, during a period of seventeen years, she had 
arthritic pains accompanied by swelling of the joints. The parts principally 
affected were the knees, shoulders, and the metacarpophalangeal joint of 
the index finger of the right hand. There were no characteristic deformi- 
ties in thifl oaae, but a well-marked "crackling" noise was observed upon 
motion of the knees.* 

The second case was that of a woman, sixty-six years of age, who after 
having lived for a long time in a very damp lodging, seemed to have had 
an attack of acute articular rheumatism. She remained in bed for six 
weeks, and two months after she got up she could not walk without crutches. 
Since that time there were occasional attacks of lumbago and flying artic- 
ular pains. At the age of forty there was a new attack of subacute artic- 
ular rheumatism. A last attack of the same kind occurred four years be- 
fore she came into the service. 

The menopause occurred in her fifty-sixth year, and it was a short time 
after this that oppression and a sense of constriction appeared. At the 



1 Op. cit., p. 61. - Op. cit., p. 129. 



132 CLINICAL LECTURES ON 

commencement of the pulmonary disease, she was for nearly two months 
unable to lie upon her bed. The attacks, always of long duration, were at 
first considerably remote from one another ; then they drew nearer and 
nearer together, so that, for about three years, the oppression and constric- 
tion became permanent, and were much increased by walking. 

When the thoracic disease assumed such a degree of intensity, the ar- 
ticular pains became vaguer and more flying. There were no deformities 
of the joints ; but very distinct " crackling " in the knees. 

After quite a long stay in the infirmary, this woman died, an extensive 
oedema of the lower limbs meanwhile having been developed. 

The autopsy revealed : 

First. — Hypertrophy of the right ventricle, without any valvular lesions, 
and without a trace of old or recent pericarditis. 

Second. — Articular lesions, almost identically the same as those of acute 
articular rheumatism, but without synovial effusion into the joint, and a 
much stronger-marked velvety condition of the osseous surfaces. 

TJiird. — Well-marked redness and evident vascularity of the mucous 
membrane of the bronchi as the pulmonary lesions ; these tubes con- 
tained a considerable quantity of greenish and tenacious mucus. 

This woman's son has long been asthmatic. 1 

It is clear that in this interesting case there was first an acute articular 
rheumatism, and then a subacute, which finally ended in the chronic form. 
The coincidence of asthma with articular manifestations in this patient is 
of capital importance from the standpoint whence we are now considering 
the subject. 

The existence of a laryngitis allied to acute rheumatism has. you know, 
been pointed out long ago. Garrod has described in addition a particular 
form of chronic laryngitis occurring in nodular rheumat 

Has pulmonary -phthisis any relation to clironic rheumatism? Tl 
still a mooted question, and one that we purpose I rthei on in 

the course. 

Urinary Apparatus. — In acute rheumatism there is a special neph 
which we have just described. Kidney-changes are almost the rule in 
gout. In chronic rheumatism albuminous nephritis is quite frequent in the 
advanced stages, according to the in v. - 3 which, together with 

Cornil, I made concerning this matter. 1 re always 

met with in those who are markedly cachectic. 

Vesical implication is quite rare in acute articular rheumatism, 
gout, and those burning pains experienced by rheumatic subjects during 
micturition, must not be confounded, the last-named sensations arising 
from extreme concentration of the mine. 

In chronic rheumatism, on the contrary, cystitis is quite frequent, 
pecially in those who have long been confined to their I 



The Nervous System. 

A. — Cerebral diseases. — We have described the striking analogies 
between rheumatic encephalopathy and the cerebral symptoms accompany- 
ing gout. Rheumatic insanity, described by Burro wa, Mesne t, and ciriesin- 
ger, is quite often associated with the subacute forms of rheumatism. 

Symptoms of this kind, in chronic rheumatism. hav t scribed by 

Fuller and Vidal. But these cases are quite rare. 

1 This case is recorded, but incompletely, in Dr. Ball's t: 



THE DISEASES OF OLD AGE. 133 

Megrim, so common in the intervals between the attacks of gout, is also 
present in the course of chronic rheumatism. 1 

B. — Medullary affections. — Chorea, whose relationship to acute articular 
rheumatism is so well established, does not seem to be present along with 
the chronic form ; at least I have never seen it "occur in the latter disease. 

Several diseases, however, that arise in the spinal marrow, are met with 
in the chronic variety of rheumatism. 

Paralysis agitans, or, at any rate, the tremor, sometimes accompanies 
partial or general chronic rheumatism. 

I have seen several cases of locomotor ataxy coincide with dry arthritis 
or nodosities of joints. But, since we now know that the arthropathies 
of ataxics may manifest themselves at the beginning of the disease, it 
becomes extremely difficult to estimate the exact part played by the rheu- 
matic diathesis. 2 

As for paraplegia, it is rarely present in either acute or subacute rheu- 
matism, and we must be well on our guard against confounding articular 
pains of spinal diseases with rheumatism in the joints ; for lesions of the 
spinal cord occasionally induce painful swellings of the articulations, as 
Mitchell, Morehouse, Remak, and several other observers attest. 

Certain lesions yet remain to be described, which, though not located 
in the internal viscera, are still abarticular. 

We have seen that gout sometimes causes affections apart from the 
joints, besides its visceral diseases ; and it is the same in the acute and 
chronic forms of rheumatism. 

Thus, the muscular pains of gout, followed by cramps and retraction of 
the muscles (Guilbert), may likewise be met with in acute rheumatism ; 
but they are much more frequent in chronic rheumatism. 

Sciatic and trifacial neuralgice, although occurring equally in gout and 
rheumatism, yet especially belong to the subacute and less intense forms of 
both diseases. They may also be met with in Heberden's rheumatism ; 
Dr. Bastian communicated a case of this kind to me. 

The visual mechanism may be affected in rheumatism as well as in gout. 
We have already spoken of gouty iritis and sclerotitis. Eye-affections are 
rare in acute rheumatism ; but it is quite the contrary in subacute (Garrod, 
Puller) and chronic rheumatism (Cornil). There is generally an iritis, but 
obstinate cases of conjunctivitis may also occur. A palpable alternation 
Taetween the ocular phenomena and the symptoms referable to the joints is 
frequently seen. 

Finally, skin diseases, so well known in gout and acute rheumatism, are 
also met with in chronic rheumatism. They are not very common in the 
intenser forms of this disease, being principally encountered in partial 
chronic rheumatism. Bazin observed, also, that cutaneous diseases are the 
more tenacious and obstinate the less marked are the arthropathies. 

We have very frequently found the skin diseases described by Bazin in 
chronically rheumatic patients : eczema, numular psoriasis, lichen, and ar- 
thritic prurigo. 

Indeed, we have often seen erysipelas allied to nodular rheumatism. 

In our next lecture we shall take up the symptomatology of chronic 
irheumatism. 

1 On this subject consult Dr. Malherbe's thesis, p. 45. Paris, 1866. 
a Charcot : Archives de Physiologie, p. 162. 1868. 



134 CLIiaCAL LECTURES ON 



LECTURE XV. 

SYMPTOMATOLOGY OF CHRONIC PROGRESSIVE ARTICULAR RHEUMA- 
TISM. 

Summary. — Three Fundamental Types of Chronic Articular Rheumatism — In Reality 
Constituting but One and the Same Disease — Chronic Progressive Articular Rheu- 
matism, or Nodular Rheumatism — Frequently Confounded with Gout, from which 
it Essentially Differs — Is Preferably Located in the Smaller Joints. 

Arthropathies arising from Nodular Rheumatism — Often Kesemble. at the Com- 
mencement, those of Acute Rheumatism —Spasmodic Retraction of Muscles — Al- 
tered Positions, Attitudes \ tcit uses— Permanent Disorders — Pain — Crackling — 
Bony Deformities— Joints which are Preferably Affected — The Hands almost 
always the First Attacked— Symmetrical Invasion — Mode of Succession of Ca- 
Arthritis — In Young Subjects, frequently Generalized from the Commencement — 
In Older Patients has a Progressive Course — Consecutive Deformities of the 
Limbs — Two Principal Tj'pes, their Varieties. 

Progress of the Disease — Secondary Changes — Atrophic Form — (Edematous 
Form — Loss of Movement. 

Deformity of the Lower Limbs— Of the Vertebral Column — Deviation of the 
Head — General Invasion of all the Joints. 

Mode of Production of these Lesions — Various Opinions — Spasmodic Contrac- 
tions — Accessory Causes. 

General Symptoms— Hematology — General Reaction — Rapid Development — 
Slow Development. 

Gentlemen : — Until now -we have regarded chronic articular rheumatism 
in only one of its aspects. The pathological anatomy of this disease has 
been, until the present moment, the object of our study ; but it is time to 
enter upon the clinical view of the question, and to present you with the 
symptomatic evidences that reveal the existence of this affection. 

We have already dwelt upon the necessity of recognizing at the outset 
three fundamental types in respect to anatomy ; and it seems equally ne- 
cessary to establish this distinction in regard to symptomatology. The 
division is, as you already know, 1st, nodular rheumatism, or prog 1 , 
chronic articular rheumatism ; 2d, partial chronic articular rheum:, 
and 3d, Heberden's rheumatism. 

These are not three distinct diseases, but three particular forms of one 
and the same affection. It is none the less indispensable to separate theni, 
for the nature and chain of symptoms, the prognosis, and even the treat- 
ment, varies in each of the three types of chronic rheumatism. 

We shall devote this lecture to progreoiive c hr o nic articular rheumatism. 

From a medical point of view, nodular rheumatism is the most int< 
ing of the three types we have enumerated. Often mistaken for gout, it 
has sometimes received the name of gouty rheumatism. "We have ah 
demonstrated to you that a radical distinction must be made in t!. 
srject. Rheumatism ought never to be confounded with gout ; but all the 
varieties of articular rheumatism are part of one and thl 
species, and should be assigned to the same category. 



THE DISEASES OF OLD AGE. 135 

Nodular rheumatism is to the other forms of chronic rheumatism what 
acute general rheumatism is to the subacute or partial variety. It espe- 
cially affects the smaller joints, those of the hand in particular. It is a dis- 
ease that too often defies all the resources of our skill, and gives rise to 
deplorable infirmities. 

We shall first describe the arthropathies induced by this disease ; and 
secondly, the symptoms arising from the constitutional condition. 

1. Arthropathies. — In the first stage the articular phenomena — if we ex- 
cept their locality — differ in nowise from those in acute or subacute rheu- 
matism. The affected joints are the seat of pain, redness, heat, and swelling 
— the same characteristics as in acute rheumatism ; but here the symptoms 
are much less intense, and are infinitely more stable. Let us also observe 
that there is no oedema, no desquamation, as we have in gout. 

This train of symptoms, however, is frequently joined by a new phe- 
nomenon, even at the very commencement — a phenomenon which is far 
from appearing with the same degree of intensity in the acute form : we 
mean that spasmodic contraction of the muscles which produces such 
strange and sometimes permanent distortions of the diseased members. 

In the second stage we have the development of lasting disorders. 
Tumefaction has occurred in the soft parts, productive sometimes of an 
hydrarthrosis, sometimes of a thickening of the synovial membrane and 
subserous tissue; it has likewise occurred in the hard parts, and then we 
observe the development of osteoids or foreign bodies, common enough in 
some joints, though rare in others, the osseous swellings deforming the 
heads of the bones, and finally, subluxations of the articular extremities. 

The pain, either spontaneous or induced, now becomes permanent ; it 
may be located in the articulation itself, the body of the bones, or the ad- 
jacent muscles, in the form of agonizing cramps. 

Then it is that we hear the crackling or crepitation due to the eburna- 
tion of the bony surfaces, if the joint still preserve a certain degree of mo- 
bility ; although very often the rigidity arising from fibrous ankylosis and 
retraction of fibrous-tissue becomes perceptible likewise at this epoch. 
Lastly appear those bony deformities that follow certain laws and rules, 
which we shall consider farther on in our course. 

And now let us see what joints are preferably invaded. This disease, 
as we have already said, has a predilection for the smaller joints. The 
larger articulations are attacked only in advanced stages of the disease, al- 
though even in cases of a general implication, the shoulder and hip are 
frequently spared. You must bear in mind, however, that the upper ex- 
tremities are almost always the first attacked ; this is just the reverse of 
gout, in which the upper limbs are only secondarily affected as a rule. 

Nodular rheumatism's mode of invasion also presents distinctive peculi- 
arities. Symmetry is here the rule, as Budd observes, a statement con- 
firmed by Komberg, and also verified as to its accuracy by myself. Gout, 
as you know, is far from following any such course as this. Let me re- 
mark, however, that in a few exceptional cases chronic rheumatism is asym- 
metrical, and the rarity of this occurrence induces me to call attention to 
it. In this instance one side of the body is first attacked, and subsequently 
the articular lesions become generalized. 

A distinction no less marked exists between gout and nodular rheuma- 
tism in regard to the parts that are first attacked. In gout it is the great 
toe ; in nodular rheumatism the metacarpophalangeal articulations of the 
index and middle fingers are the first invaded, and this, too, on both sides 



136 CLINICAL LECTtTPwES ON 

of the body simultaneously, in conformity to the law of symmetry we have 
enunciated. Do not forget, however, that this disease begins in a large 
joint much more often than gout, and this fact alone frequently aids us in 
making a diagnosis. In connection with this question let me adduce also 
a few statistics : 

First. — Hands and feet alone, smaller joints 25 times. 

First. — — — — — The great toe 4 times. 

Second. — Hands and feet along with a large articulation . . 7 times. 

Third. — A large joint at first, and later on the fingers. ... 9 times. 

Let us now look at the mode of succession of arthritises in nodular rheu- 
matism. In the majority of cases they develop from the periphery toward 
the centre ; the fingers are first implicated, then the elbow, then the shoul- 
der. This regular succession, however, is met with only in those cases 
where the disease develops slowly. In young patients, from sixteen to 
twenty years of age, this affection, on the contrary, is often general from the 
outset ; but in older subjects, from forty to sixty, it follows the progressive 
course we have just described. In the first case the disease is evolved rap- 
idly ; in the second it develops slowly. But nothing is absolute in this re- 
spect, since often, at the menopause, the symptoms occur abruptly and the 
malady presents all the traits of an acute disease. 

We have yet to describe the deformity of the limbs that results from 
this morbid action. They are especially marked in young subjects when 
spasmodic pains are present and muscular retractions are excessive. We 
do not speak now of deformities of the joints themselves, but of the faulty 
positions arising from a change in the relation between the various seg- 
ments of the limb. 

These deformities are almost always identical ; they obey regular laws. 
In the case of the upper extremity they may be divided into two principal 
types, with secondary derivatives. 

In both cases the hand is more or less exaggeratedly pronated. This 
characteristic belongs to each in common ; but they diner in many other 
respects. We shall give a succinct description of all of them. 

First type. — This is the one most frequently met with. 

It is characterized : 

fl. — By flexion at an obtuse, right, or even acute angle of the terminal 
phalanx upon the middle phalanx. 

b. — By extension of the middle phalanx upon the proximal phalanx. 

c. — By flexion of the proximal phalanx upon the metacarpal beads. 

d. — By flexion, at a less obtuse angle of the metacarpus and carpus upon 
the bones of the forearm. 

e. — In a great number of cases by an inclination, en mane, of all the 
phalanges toward the cubital (ulnar) side of the hand, and then a twisting 
in the opposite direction of the middle upon the proximal phalanges. The 
former of those two lesions is often one of the first deformities 
the advent of this disease. 

This type presents two varieties. In the first, most of the cbaraeti 
tics we have described are preserved ; but the proximal and middle phalan- 
ges are in the same plane, have the same axis, and form a single column. 

In the second, flexion of the terminal upon the middle phalan. 
sent, and then the fingers seem hollowed or excavated, starting froin the 
projecting metacarpal heads. 



THE DISEASES OF OLD AGE. 



137 



Second ft/pe.^This is marked : 

a. — By extension of the terminal phalanx upon the middle phalanx. 




Fig. 20.— First type. 



b. — By flexion of the middle phalanx upon the proximal phalanx. 

c. — By extension of the j^roximal phalanges upon the metacarpal heads. 



4J=E 




Fig. 21.— First variety of Type 1. 

d. — By a more or less pronounced flexion of the carpus upon the bones 
of the forearm. 




Fig. 22. — Second variety of Type 1. 



e. — In certain cases, by a deviation, en masse, of the proximal phalanges, 
which are visibly inclined toward the ulnar side of the hand. 




Fig. 23. — Second type. 



138 CLINICAL LECTURES ON 

This type, like the preceding, may present two varieties. 
In the first, there is flexion of all the articulations of the hand, consti- 
tuting, after a fashion, a kind of scroll. 




Fig. 24.— First variety of Type 2. Fig. 25.— Second variety of Type 2. 



In the second we observe the same thing, except that, in addition, 
there is extension of the middle upon the proximal phalanges. 

Hitherto we have only considered the deviation of the fingers of the 
hand ; what becomes of the thumb ? 

Here, as elsewhere, the metacarpophalangeal articulation is especially 
altered. The first phalanx of the thumb is often flexed, though sometimes 
extended. 

The other articulations of the upj)er extremity partake, in a certain 
measure, in these deformities. 

Thus, flexion of the elbow is more or less marked — indeed, is sometimes 
exaggerated ; extension is impossible. 

The forearm is pronated. 

There is more or less complete flexion of the carpus and the metacarpus 
upon the forearm, with projection of the ulna and radius. 

Finally, the shoulder is sometimes rigid, and the whole upper extremity 
is fixed against the thoracic wall. 

We shall next consider in what manner, and in what order, the articula- 
tions of the upper extremity are invaded. 

Two cases may present themsel 

A. — In young subjects the disease progresses rapidly, and spasmodic 
contractions of the muscles being very marked, the deformities are distinctly 
exhibited. There is projection of the heads of the bones following upon 
subluxations that have occurred in the joint. 

Thus, in the second type, there is considerable projection of the bones 
of the forearm behind the carpal bones ; there is a subluxation of the heads 
of the proximal phalanges, in front and to the outside, producing quite 
prominent projections upon the back of the hand ; and there is a slightly 
marked subluxation of the middle phalanges forward upon the proximal 
phalanges, the heads of which bones bulge upon the palm of the hand. 
Finally, on account of prolonged flexion of the terminal upon the second 
phalanges, the small condyles of the latter project behind. Attention must 
bewailed to the fact that the osseous vegetations around the digital ai 
lations do not constantly circumscribe the heads of the bones : sonu I 
there are tubercles, sometimes more or less elongated needles. At am 
these osteophytes contribute but slightly to the deformity of the joint* 

^ And lastly, in the form we are discussing, there is more complete immo- 
bility, on account of the greater rigidity of the ligaments and fibrous tis- 
sues : fibrous ankylosis soon results, and thus a rapid wasting of tlu 
is induced. The term nodular rheumatism is scarcely applicable to otfl 
this sort. 



THE DISEASES OF OLD AGE. 13 9" 

B. — In older subjects the disease develops more slowly, and the power 
of movement is partly retained. Deviations from the normal are much 
less strongly marked, and the size of the heads of the bones and of the os- 
seous stalactites is greater. 

There is, in reality, a sort of inverse proportion between the degree of 
deviation and the size of the bony swellings, as well as the extent of the 
deformities resulting from the latter. 

"When the disease is prolonged beyond a certain period of time, changes 
are produced which are the results of this state of affairs. Atrophy of 
bone, atrophy of muscles and wasting of the soft parts are the commonest 
occurrences in such cases. 

We can distinguish, however, two opposite forms here : in the atrophic 
variety (Vidal) there is induration of the skin — a kind of scleroderma : the 
cutaneous investment is cold, pale, smooth, and shining, no longer wrink- 
ling. 

In the other form an oedematous infiltration, simulating elephantiasis, 
occurs in the member, and this swelling is frequently accompanied by in- 
flammatory symptoms ; these phenomena are especially manifested in the 
lower limbs. In all cases the muscles of the limbs finally undergo a cer- 
tain degree of atrophy and fatty degeneration on account of the immobility 
of the parts. 

The immediate result of these changes is that the patients are debarred 
of movement in the upper extremities, and are no longer able to feed them- 
selves. Then appear those ingenious inventions — those long forks whose 
form and dimensions vary according to the infirmity of the sufferer, but 
whose object is always to enable them to convey food to the mouth, 
thanks to the more or less restricted power of movement they still 
possess. 

In this connection let me remark that the right hand, with which the 
patients continue to feed themselves, does not present in its deformities 
so regular a type as the deviations in the left, which, in the vast majority 
of cases, becomes absolutely immovable. 

And now let us look at the articular lesions that may occur at other 
points in the skeleton. 

The lower limbs are occasionally free from implication, and this when 
the hands have suffered the most marked changes. But such cases are 
rare, and generally the lower limbs are deformed symmetrically ; there is 
deviation of the segments, and they become incapable of producing ordi- 
nary movements. 

The hip-joint usually preserves its freedom, but the same cannot be 
said of the knee. In the majority of cases there are flexion of the thigh 
upon the abdomen, and flexion of the leg upon the thigh. The principal 
deformities are as follows : 

The lower end of the femur projects in front of the head of the tibia. 

The internal condyle of the femur becomes protuberant. 

The patella, thrown to the outside, rests upon the external condyle. 

The head of the fibula projects backward. 

Complete ankylosis at the knee-joint is, however, a rare occurrence ; 
but bony swellings are almost always developed there, and foreign bodies 
may be met with in great abundance in this locality. 

In the tibio-tarsal articulation, on the other hand, ankylosis is very fre- 
quent. The foot may be abducted, then resting upon the external border, 



140 CLINICAL LECTURES ON 

thus simulating talipes valgus; and it may, on the other hand, be carried in 
abduction : then we have a talipes equino-varus. 1 

The great toe is carried outward so that it covers the other toes. 

Important deformities may likewise occur on the part of the cervical 
vertebras. In several cases that I observed myself in the Salpetriere, I have 
seen the head bent forward and flexed upon the sternum, so that the chin 
nearly touched the chest. The movements of the head were very limited, 
and caused crepitating or crackling sounds when attempted. In the major- 
ity of these cases the neck was noticed to be enlarged posteriorly. 

And it is in this way that most of the joints may be attacked in one and 
the same individual, in a case of general chronic rheumatism ; and then the 
unfortunates are condemned to remain in bed during the remainder of 
their existence. They sometimes live more than twenty years in this mis- 
erable condition. 

The mode of production of these deformities yet remains to be studied. 
Some physicians ascribe them to a providential action (Beau) which aims 
at palliating the intensity of the pain ; others believe them to be the result 
of attitudes which the patients instinctively assume (Trastour). 

I profess, myself, a diametric-ally opposite opinion on this subject. In 
the majority of cases these deformities come from spasmodic, and, as it were, 
convulsive, muscular contract tons. They are produced by a sort of reflex 
action whose starting-point is in the diseased joint 

I shall not dwell long upon this subject. The arguments that I have 
previously advanced, reinforced by those of Crocq, appear to me to have 
incontrovertibly proved that these results are produced in precisely this 
manner. 

In this regard we may adduce : 

Fii'st. — The very form of the deviations or deformities ; they are mani- 
festly forced actions. 

Second. — The resistance that the patients offer to these spasmodic retrac- 
tions, which, although impotent to prevent them, is sufficient proof that 
they are involuntary. 

Third. — The general aspect of the deformities, which certainly accords 
with idea of muscular spasm : they are, indeed, deformities or deviations as 
a whole, even when the joints brought into play are not all implicated. 

Fourth. — Finally, the presence of the same deformities in cases where 
the joints are in nowise affected ; they can then be ascribed to the spasmo- 
dic contraction of muscles alone. 

Thus, in paralysis agitans, in congenital cerebral atrophy and in atrophy 
of the interosseous muscles, the parts occasionally assume a form in every 
respect the same as that observed in chronic articular rheumatism. 

Moreover, it would be impossible to deny the existence of accessory in- 
centives in addition to the fundamental cause of rheumatic deformities. 
The weight of the limbs, the greater or less laxity of the ligaments, have a 
correspondingly important part to play in the production of these deviations 
from the normal ; but these various conditions are insufficient in theme 
to induce similar' effects without the concurrence of muscular* retraction. 
Do we not see in certain cases of hydrarthrosis exceedingly great laxity of 

1 This is an exact and almost literal translation of the original paragraph. I think 
the word external should be internal {interna in place of extern*^ and that ti 
Eduction should read Eduction. — L, H. H. (See Eriohsen'fi Sundry. >e\ enth edition. 
Vol. ii., pp. 309-371 inclusive.) 



THE DISEASES OF OLD AGE. 141 

the ligaments of the knee, without any subsequent deformities resulting 
therefrom ? On the contrary, the part remains absolutely flaccid. 

As we have seen, the deformities that have just been described do not 
belong exclusively to rheumatism. But the changes in the joints, the 
crackling or crepitation, the hydrarthrosis, the fibrous ankylosis, and con- 
sequent rigidity of the articulation, the symmetry of the lesions — all these 
distinguish the effects of chronic rheumatism from those produced by par- 
alysis agitans and various other diseases. But gout gives rise to the same 
spasmodic contractions, and to the same deformities and deviations. In 
his " Treatise on Gout," Guilbert has dwelt at length upon these muscular 
retractions. 

The presence of tophi, however, which accompany in the majority of 
cases this kind of deformity in the gouty, is a truly pathognomonic charac- 
teristic. In rheumatic patients nodosities occasionally perforate the cuta- 
neous investments ; but the part exposed is bone, and not a chalk-stone, as 
in gout. 

General Symptoms — Course of the Disease. 

A. — Hematology and a chemical study of the secretions have as yet 
given only negative results. 

Musgrave says the blood is buffed (couenneux) ; it certainly is in the 
acute forms, but we never find any uric acid in it. I have, myself, exam- 
ined the blood in thirty-five cases of chronic articular rheumatism, without 
ever discovering the least trace of this substance. 

In a case reported by Bocker, the chemical analysis furnishes most in- 
teresting results. This case is cited as one of gout, but it may certainly be 
attributed to nodular rheumatism, for the extremities of the bones were 
swollen — a thing that never happens in gout. The blood and the urine were 
examined, and in the urinary secretion there was a marked diminution in 
the normal proportion of phosphate of lime, while, on the contrary, the 
blood contained four times more phosphate of linie than normally present. 
It appears that the ordinary quantity of uric acid was not increased— at least, 
the author is silent upon this point. 

B. — From a standpoint of general reaction and the progress of the dis- 
ease, we have to recognize two essentially distinct forms. 

In chronic articular rheumatism that develops rapidly, the disease is 
usually in young subjects froni sixteen to thirty years of age, or in women 
who are pregnant or in the puerperal state ; moral emotions and impres- 
sions of intense cold may likewise exert a certain amount of influence. 

In such a case we see a large number of joints simultaneously attacked. 

Muscular retractions are more pronounced, pains are very severe, red- 
ness and swelling are quite marked, and the disease is less unstable than in 
its opposite type. 

The general symptoms are those of acute or subacute articular rheuma- 
tism ; we notice marked elevation of the temperature, manifest acceleration 
of the pulse and profuse perspiration. It is in these cases especially that 
cardiac affections are met with. 

It might be admitted here that rheumatism, at first acute, has later on 
assumed the chronic form ; this opinion, which has been upheld by vari- 
ous writers, may be true in a few cases. Dr. Ball brought me a patient 
in whom the metacarpophalangeal articulations were attacked during the 



142 CLINICAL LECTUBES ON 

course of an attack of acute articular rheumatism. The result was a devia- 
tion of the fingers toward the ulnar side of the hand ; and this man, who 
to-day remains wholly recovered, still carries these characteristic deformi- 
ties of nodular rheumatism. 

We think, however, that, in the vast majority of cases, such examples are 
chronic rheumatism from the outset, but that the course of this chronic 
form presents some of the characters of acute rheumatism. 

After a certain period of time, a remittent fever is developed, resembling 
hectic fever ; and then we witness the occurrence of a series of exacerba- 
tions followed by long intervals of remission. 

In cases of this kind the disease usually lasts but for a comparatively 
:short time. After two, three, or four years the joints almost completely 
cease to be painful, and the case remains, then, in that condition. Some- 
times, indeed, these deformities cease to exist after having been produced. 
We have observed cases of this kind ourselves ; unfortunately, they are only 
too rare. In this way, also, a woman who was at first attacked with sub- 
acute febrile rheumatism affecting the shoulders and the nietacarpo-phalan- 
geal articulations, three months after the commencement of the di 
suffered spasmodic retraction of the fingers ; this secondary deformity lasted 
during an entire year, and then the patient recovered. 

Chronic rheumatism that develops dotdy, generally occurs in older 
subjects, from forty to sixty years of age : this ten met with it 

the time of the menopause. Geist ' described this fomi under the name of 
senile gout. It is here especially that we meet Haygarth's m 
the joints. 

One by one the articulations are invaded in succession ; in these c 
therefore, the mode of invasion can best be studied. Pain is ]. 
and there is less redness ; indeed, it is often wholly wanting. The devia- 
tions resulting from muscular contractions are less marked, but, on the 
other hand, the deformities of each joint are much more prominent. 

Concerning the general bodily condition, it may be said that it is but 
rarely accompanied by febrile movement ; only from time to time 
rise in the temperature observed. Finally, taken all in all, the prognosis is 
not so grave as in the preceding form. 

We have compared these two extreme varieties in order to expose their 
analogies and their differences, but between these two forms there is a num- 
ber of intermediate stages, establishing a gradual transition. Let me 
remark, too, that, notwithstanding the rule which we have enunciated, cases 
are met w T ith in younger subjects that are the counterparts of those occur- 
ring in the aged : and the converse also holds good. 



Klinik der Greisenkrankheiten. Erlangen. 



THE DISEASES OF OLD AGE. 143 



LECTURE XVI. 

SYMPTOMATOLOGY OF PARTIAL CHRONIC RHEUMATISM AND OF HE- 
BERDEN'S NODOSITIES. 

Summary. — Partial Chronic Rheumatism — Various Denominations it has Received — 
Does not Essentially Differ from Nodular Rheumatism — Its Particular Character- 
istics — Small Number of Joints Affected — Larger Articulations oftenest Involved 
— Insidious Advent — The Form Chronic from the Commencement — Articular De- 
formities — Diathetic Manifestations — Cutaneous Diseases — Visceral Affections. 

Mode of Development — Occasionally succeeds Acute Rheumatism — May show 
Itself at the Beginning- — Sometimes Generalized. 

Articular Phenomena — Deformity — Pain — Absence of Sensibility on Palpation — 
Crackling or Crepitation. 

Prognosis Comparatively not Serious — More or Less Complete Abolition of 
Movements — Spasmodic Retraction of the Muscles quite Rare — Extreme Rigidity 
of the Articulation. 

Nodosities of Heberden — Independent of Gout — Are Located around the Articu- 
lation of the Terminal Phalanges — Lesions are Identical with those of a Dry Ar- 
thritis — Other Joints of the Hand frequently Involved, but to a Less Degree — 
This Affection Accompanies the Rheumatic Diathesis — It may, though very rarely, 
Coincide with Gout. 

Gentlemen : — We shall complete the description of chronic rheuma- 
tism's symptoms by a study of the two chief forms of this disease following 
upon nodular rheumatism, in the classification we have adopted. We mean 
partial chronic rheumatism and Heberden s nodosities. 

Partial chronic rheumatism, to which we shall first devote our attention, 
has received a large number of appellations varying with the different 
writers upon the subject. When located at the hip-joint, it is called mor- 
bus coxae senilis ; it has been denominated senile arthritis, and dry arthritis, 
when it had its seat elsewhere. It is the disease that produces the most 
characteristic deformities : it is arthritis deformans. 

This disease does not essentially differ from the preceding ; it is marked, 
however, by a few peculiar symptoms. Several of these we have already 
described. And now we wish to recall the most characteristic differences 
that separate these two forms of one and the same disease. 

First. — A small number of the joints is involved, in comparison with 
what occurs in general rheumatism. 

Second. — The larger joints, and even those which, in the preceding 
form, only suffer in very rare instances, are here the ones oftenest attacked. 

Third. — The form that is chronic from the onset is here the rule. In 
the majority of cases it begins insidiously ; pain is not very marked, and 
the affected members usually preserve their mobility — that is, to a certain 
extent. But, on the other hand, considerable deformity frequently occurs 
about the joints, on account of the exuberance of the osseous swelling ; 
and besides, we sometimes meet with an hydrarthrosis sufficient to aid in 
the deformity. (Hypertrophic form of Adams.) 



144 CLINICAL LECTURES ON 

This disease has been especially studied from a standpoint of external 
pathology, and investigators have more especially devoted their attention 
to those cases where the disease was localized in a single articulation. In- 
deed, the diagnosis may then present the greatest difficulties ; for this 
form of rheumatism may simulate a luxation, a fracture, and still more, a 
white swelling. These are questions that have always attracted the atten- 
tion of surgeons ; nevertheless, the study of this disease possesses a great 
interest for the physician — indeed, it involves the question of a disease 
almost always diathetic, which may frequently be accompanied by cutaneous 
affections, 1 and by visceral lesions (asthma and cardiopathies) whose sig- 
nification is shown by the very fact of their coinciding with chronic arthrop- 
athies. 

It may be observed, besides, that the localization of the disease in a 
single joint, the latent development of the malady and the extreme preva- 
lence of bony swellings of new formation, are facts that are rather the ex- 
ception than the rule, and facts that are especially striking from their very 
rarity. The arthropathies of partial chronic rheumatism very frequently 
appear with all these characteristics — in a very inferior degree, it is true, but 
nevertheless perfectly appreciable. This fact is of great clinical importance, 
for the well-established existence of these arthropathies may become an 
easily comprehended index of the rheumatic diathesis ; and it is from this 
point of view that it is of significant interest to us. 

I shall not undertake, gentlemen, to give you a description in due order 
and form of this variety of rheumatism ; it belongs especially, as I have 
said, to the domain of surgery, and on that ground I do not wish to en- 
croach. But I must needs acquaint you with certain of its characteristics, 
which, considered from the standpoint we have taken, j>ossess the highest 
importance for us. 

A. — Chronic partial rheumatism occasionally appears to succeed acute 
articular rheumatism, and thus becomes its consequence. 

Adams, who has made a special study of this question, recognizes this 
mode of development of the morbid phenomena. In such circumstances it 
is one of the forms of node-articular rheumatism. Two varieties may oc- 
cur : sometimes the rheumatism degenerates into a white swelling ; some- 
times it assumes the characters of arthritis deformans. The latter happens 
oftenest, and in this transition there is nothing to excite any surprise, since 
we know that acute rheumatism has, at its inception, the lesions of the 
chronic form. 

B. — The commencement of arthritis deformans may be acute, while the 
rheumatism is partial from the onset. Adams : and Colombel s record ex- 
amples of this, and I have myself observed a few such cases in 1 * riere. 
Thus, a woman fifty-three years of age had. at the beginning, acute partial 
arthritis, with fever and muscular retraction ; then the disease pen 
under the form of a dry arthritis ; finally symmetrical pains occurred in 
both hands, and the disease passed into nodular rheumatism. 

C. — On the other hand, the disease, as we have already seen, may con- 
mence slowly and insidiously, the symptoms remaining localized in a sin- 
gle joint from the start ; but the real nature of the disease is in the end 
revealed by one or more arthritises, or of some abartieular manifestations 
allied to the rheumatic diathesis. There is now in : >man, 

1 See Colombel : Recherches sur l'Arthrite Seche. Th: b m>3. 

8 Op. cit. Obs. xvii., pp. 44 and 301. 



THE DISEASES OF OLD AGE. 145 

forty-six years old, who, after first having a dry arthritis of the hip-joint, 
was later on attacked by a similar condition of the knees. Another patient, 
a woman, sixty- three years old, first had dry arthritis of the right hip-joint, 
next of the left, and then a painful swelling of the left knee with crepita- 
tion ; finally the nodosities of Heberden made their appearance. 

D. — Lastly, quite a number of cases are met with where rheumatism, 
after having been stationary for a longer or shorter time upon a certain 
number of joints, becomes general. Two opposite transformations may 
be met with : at times partial rheumatism becomes general ; and again, 
on the other hand, a single articular affection is observed to predominate 
in a case of general rheumatism, and the affected joint finally develops the 
lesions of arthritis deformans. Several examples of this are recorded by 
Adams. 

Among others, he quotes the case of Dr. Percival, a very distinguished 
physician, who died in 1839, at the age of eighty-two, after having long 
suffered from this disease. In 1818 he had quite severe pains in the hands 
and wrists, accompanied by slight swelling. Tsvo years later there was a 
little pain in the right coxo-femoral articulation, and gradually walking 
became extremely difficult to him. The limb was shortened and rotated 
externally ; its movement was accompanied by well-marked crackling ; and, 
when at rest, the limbs were crossed ; he could not move from this atti- 
tude without inducing pain. Five years before he died analogous symp- 
toms occurred in the left hip-joint. 

Dr. Percival's death was caused by a disease of the bladder ; and, in 
conformity with his last wishes, an autopsy was made by Dr. Colles, and 
the specimens were presented to the Pathological Society of Dublin. The 
articulations presented the most characteristic type of senile arthrocace ; * 
the heads of the bones were flattened and eburnated, as were also both 
acetabuia. The ligamentum teres had completely disappeared. The neck 
of the femur was shortened ; the head of the left femur was reddened and 
vascularized, numerous bony deposits covering the capsular ligament. 

In the case of a woman of sixty, who had suffered from nodular rheu- 
matism for twenty- five years, the disease finally became localized in the 
knees, which were ankylosed at right angles, and presented all the typical 
symptoms of a dry arthritis. 

But, in whatever way partial rheumatism originates, it is rather an in- 
firmity than a disease when once it has attained the chronic stage. I make 
an exception here of the visceral lesions that may follow in its train. We 
must not forget, however, that acute exacerbations occasionally occur. 
The articular affection that has so long been painless, finally gives rise to 
intense sufferings, the skin reddens, and we mark an evident aggravation 
of the chronic symptoms. 

The purely articular phenomena, when the disease is regularly estab- 
lished, are the following : 

First. — There is more or less pronounced deformity of the joint ; os- 
seous ridges or crests, foreign bodies, and hydrarthrosis, are present. 

Second. — The patient suffers spontaneous pains, quite vague in charac- 
ter, which pass off as he walks, but which finally become excruciating as 
the malady progresses. 

Tliird. — No pain — or almost none — is produced by palpation or percus- 
sion — a peculiarity which distinguishes this arthropathy from those of a 
serious nature. 

1 Arthrocace —ulcer of bone ; (?) osteo-sarcoma. — L. H. H. 
10 



146 CLINICAL LECTURES ON 

Fourth. — There is always more or less well-marked crackling or crepi- 
tation. 

This disease, when exempt from all complication, in no wise threatens 
life ; but it does away, more or less completely, with the movements of the 
parts affected. Nevertheless, the patients frequently continue to walk, 
though not without some difficulty. It is in these cases that the autopsy 
reveals striations upon the eburnated portions of the cuticular surfaces of 
the bones of the joint. 

Spasmodic retraction of the muscles is very rare here, save at the com- 
mencement, but occasionally the ligaments are extremely relaxed ; or, 
again, as we so often observe in the hip, there is very great rigidity of the 
articulation, on account of the deformity of the heads of the bones, or of 
their receptive cavities. 

Nodosities of Heberden. — We now purpose to consider 11 
ities, a special form of chronic rheumatism that has not yet been sufficiently 
described, and which, indeed, writers scarcely mention. Must physicians 
confound it with gout, without reserve or restriction. 

We readily see that nodular rheumatism differs from true gout in many 
characteristics ; but, in the case of Heberden'fl nodes, we are told that 
to doubt any longer would be unreasonable — the disease certainly is 
gout. 

Personally, I hold the contrary opinion ; and I designate this form of 
rheumatism by the name of nodositi>'* of Heberden, because this author was 
the first to recognize that these lesions ought to be separated from those 
of gout. 

"What," he says, in his " Commentaries," "what is the nature of the 
small, hard nodules, about the size of a pea. that we so frequently meet 
with in the fingers, especially upon their extremities, near the joint? Tkey 
have no connection with gout." 

These little nodosities, as Heberden observes, have their seat at the 
articulation of the terminal phalanges. The digital extremity is in general 
but slightly deviated either to the right or left. There are two nodules on 
a level with the joint, which seems, besides, a little enlarged. There is 
rigidity, but no crackling or crepitation, in the diseased articulation. 

In the majority of cases the advent of this condition is vary obscure ; 
but during attacks, or "fits," we have pain, heat, and temporary swelling 
of the soft parts. These are genuine attacks, which the patients often re- 
gard as gouty. 

The minute anatomical lesions of this arthropathy have n< been 

described. According to the numerous investigations which I had the 
opportunity of making at the Salpetriere, we find the changes of a dry 
arthritis here, as in the case of the two other forms of chronic articular 
rheumatism ; I have ascertained this fact myself in many dissections. The 
articular cartilages undergo the "velvety" change; then they disappear, and 
we find in their place a layer of eburnated bony tissue. The articular sur- 
faces are enlarged in all directions, on account of the formation of 
phytes which, while enlarging them, almost reproduce their normal form 
and contour. The pisiform tumors that, according to Heberden's descrip- 
tion, are met with in the vicinity of the second phalangeal articulation, are 
nothing but osseous tubercles, which are normally present at the lower 
extremity of the dorsal aspect of the second phalanx : but there is a con- 
siderable increase in the volume of these tubercles from the apposition of 
new osseous layers. There is not a trace of urate of soda, either in the 



THE DISEASES OF OLD AGE. 147 

deeper portions of the articular cartilages, or in the soft parts in the vicin- 
ity of the joints. 

The remaining joints of the hand are usually affected, although to a 
much less extent. Contrarily to what occurs in nodular rheumatism, the 
lesions are best exhibited upon the articulations of the proximal with the 
second phalanges, and secondly, on the line of the metacarpophalangeal 
articulations. 

These nodosities are interesting to us, since they reveal a constitutional 
condition, which is neither more nor less than the rheumatic diathesis. 

This disease, of very frequent occurrence in the Salpetriere, belongs 
especially to the senile period of life ; but it must not be thought that it is 
never met with in young subjects ; quite the contrary, we often observe it 
at far less advanced years, and this is an important point to demonstrate. 
Here is an hereditary disease ; it may manifest itself in several members of 
the same family. It has palpable relations either with nodular, or espe- 
cially with partial rheumatism ; indeed, it is frequently seen to accompany 
arthritis of the hip or knee. 

It sometimes happens that, in the same family, some have Heberden's 
rheumatism, others general chronic rheumatism, and still others partial 
rheumatism ; another proof of the bond uniting these three forms of one 
and the same disease. 

Heberden's rheumatism is often coincident with asthma, megrim, neu- 
ralgia? — especially sciatic neuralgia, and muscular rheumatism. These 
manifestations may likewise alternate with acute attacks of this disease. It 
is not rare to meet with it in individuals suffering from cancer of the breast 
or of any other organ. 

Lastly, these nodosities may occur in gouty subjects, as I had the 
opportunity of noticing quite recently. But in the case in question they 
preceded gout by several years. 



148 CLINICAL LECTURES OX 



LECTURE XVII. 

ETIOLOGY OF ARTICULAR RHEUMATISM. 

Summary. — The Principal Causes of Articular Rheumatism — Are Common to all the 
Forms of this Disease — Historical Pathology — Preponderance of Gout in the 
Writings of Physicians of Antiquity — Xodular Rheumatism, however. Already 
Recognized — Medical Geography — Acute Articular Rheumatism, a Disease beloDg- 
ing Especially to Temperate Climes — Unknown Around the Polar and Equatorial 
Regions— Chronic Articular Rheumatism Abounds in Temperate Climates, but 
likewise Occurs in Hot Countries — Heredity : its Incontestable Influence- 
tistics taken from Various Authors — Age — The Classical Period for Acute Rheu- 
matism between Fifteen and Thirty Years — Chronic Rheumatism Especially met 
with at Two Periods of Life : from Twenty to Thirty, and from J - \ty — 

Sex — Men more Liable to Acute Articular Rheumatism — Women to Nodular 
Rheumatism. 

External Causes — Wet Cold — Damp Habitations— Poverty. Insufficient Alimen- 
tation — Traumatic Causes — Blows. Fall>, Phlegmon, Whitlow — Pathological 
Causes — Erysipelas — Angina — Scarlatina — Blennorrhagia (Gonorrh 

Uterine Functions— Chlorosis — Dysmenorrhoea — Menopause — Pregnancy — Pro- 
longed Lactation. 

Comparison between the Etiology of Rheumatism and that of Gout — These Two 
Diseases not Identical, but a certain Degree of Relationship Exists between Them. 

Gentlemen : — The study of the causes which preside over the develop- 
ment of articular rheumatism furnishes new proof in support of the theory 
we have constantly upheld. 

Indeed, upon the ground of etiology, we shall see the various forms of 
this disease approximate and become intermingled ; we shall see them, on 
the other hand, diverge farther and farther from gout. And thus we shall 
establish the fact that the types apparently so different, which we have de- 
scribed heretofore, acknowledge essentially a common origin. 

It must not be overlooked, however, that, according to a few observa- 
tions, articular rheumatism has induced a predisposition to gout thi 
the influence of heredity ; and the converse of this seems, ako, to be none 
the less certain. 

I. — Historical pathology and medical geography. — While we were studying 
the history of gout, we stated that articular rheumatism had received but 
very little attention on the part of the physicians of antiquity, who- 
scriptions are almost wholly confined to gout : that they likv found 

the latter disease with rheumatism under the name of the articul 
(articulorum passio). Baillou is the first writer who g 
scription of rheumatism ; and the proof that this distinction requi 
time to become established is to be found in the fact that it was not yet 
admitted in the first editions of Boerhaave. 

The silence of the physicians of antiquity ha 
imagine that rheumatism did not appear before modern tinn - 
found in the ruins of Pompeii afford us more positive information on this 



THE DISEASES OF OLD AGE. 149 

point than medical literature can furnish, at least so far as chronic rheuma- 
tism is concerned, since in many instances the characteristic lesions of this 
disease were actually found among the human remains. Most valuable and 
important information on this subject can be found in the " Osteologia 
Poinpeiana," by Professor Delle-Chiaje of Naples. The plates accompanying 
the text banish every doubt from the mind of the reader. 

A medical geography has yet to be written. Under the influence of cer- 
tain preconceived ideas a deplorable confusion has arisen among all the 
diseases which trace their origin to cold ; and it is easily understood how 
difficult becomes the task of criticism when observations made in remote 
regions are to be examined and tested. 

It seems to be established, however, that acute articular rheumatism is 
a disease that abides more especially in temperate climates : it is unknown 
in the immediate vicinity of the poles and the equator. But this disease is 
quite frequently met with in hot countries : it often occurs in Egypt, ac- 
cording to Pruner-Bey, and in the East Indies, according to Webb ; in the 
latter country it is frequently complicated by an endo-pericarditis. 

At the Cape of Good Hope, the geranium's native home, the number of 
cases of rheumatism in one thousand sick in the English army, was^?/b/- 
seven ; while in the rigorous climate of Nova Scotia there were only twenty 
suffering from rheumatism in the same number of patients. 

Concerning chronic articular rheumatism, we possess no positive infor- 
mation, although it is at least certain that it prevails in temperate climes : 
in England, Ireland, France, Germany, and all Central Europe. But it may 
also occur in hot countries. In India, Malcolmson has found it among the 
Sepoys ; and I myself have observed that it is a frequent disease in Naples. 

II. — Heredity. — The study of this question possesses the greatest im- 
portance for the theory of rheumatism, since hereditary diseases are not 
accidental and transient, — they are in the very constitution of the patient ; 
this is well seen in the case of gout. 

The statistics of Chomel and Kequin here establish the frequency of 
hereditary transmission ; unfortunately, however, these authors confounded 
gout with rheumatism. But Fuller, who holds to the distinction between 
them, found the hereditary transmission of rheumatism 96 times in 300 
cases, or a proportion of 29 per cent.; 1 while for gout the proportion is 50 
per cent. 

New investigations are indispensable in the case of chronic articular 
rheumatism. Still, all we do know of it tends to establish the fact that this 
disease often proceeds, because of an hereditary tendency, either from 
acute rheumatism, or directly from chronic rheumatism. 

There can be no doubt upon this subject as regards vodular rheuma- 
tism. In forty-five cases of this type, Trastour states that the father and 
mother were rheumatic ten times, and three of the female patients had 
children who were already attacked with articular rheumatism. I observed 
an interesting case of this kind myself. There is now in the Salpetriere a 
woman that has nodular rheumatism, whose daughter and grand-daughter are 
already suffering pains in the smaller joints. Here are three generations 
successively attacked with the same disease. 

1 Prof. Charcot says : "96 fois sur 300, ce qui dorme une proportion de 29 pour 
100." It should read " 87 times in 300 cases." See Reynolds : A System of Medicine. 
Vol. i., p. 938.— L. H. H. 



150 CLINICAL LECTURES ON 

In Heberden's rheumatism, heredity seems established according to per- 
sonal observations of my own ; this is very frequently a family disease, a 
point to which Garrod has already drawn attention. 

Concerning partial chronic rheumatism, the question is still under inves- 
tigation, and I will not venture an opinion thereon. 

HE. — Age. — The classical time for acute articular rheumatism is between 
the ages of fifteen and thirty, although this disease is not rare in the ear- 
lier years of life; it develops in children of five and ten, and, according 
to West and the majority of writers, heart disease is more frequent in 
young people than in older subjects attacked with this form of rheuma- 
tism. 

And here is a difference to be pointed out between this disease and 
gout, inasmuch as the latter is rarely developed before the twentieth year, 
as we have already stated (p. 87). 

The acute form of articular rheumatism seldom occurs after the age of 
fifty. In one hundred and ninety-nine cases, Macleod saw it develoj) only 
once after fifty-five years of age ; and Fuller, out of two hundred and 
eighty-nine cases, observed only seven after fifty years of age. 

I have seen two cases of this kind occurring after seventy years. The 
first case was a slight acute rheumatism, and the second was subacute 
febrile rheumatism of a very obstinate nature. 

For nodular rheumatism, Trastour and myself have proved that there are 
two periods of life when one is more particularly liable to suffer an attack; 
it is from twenty to thirty, the epoch of complete development, and from 
forty to sixty, the time of the menopause, that this disease preferably ap- 
pears. Thus Haygarth was wrong in ascribing chronic rheumatism almost 
exclusively to the menopause. 

Nevertheless, this disease may manifest itself either before or after the 
periods we have named. We have many observations that are sufficient 
proof on this point. 

Thus, Laborde brought before the Society de Biologie a little boy. eight 
years old, who had all the characteristic deformities of nodular rheumatism; 
the disease commenced when he was four years of age. I have already de- 
scribed, when speaking of rheumatic pericarditis (p. 180), the remarkable 
case that Martel recorded in the service of Dr. Barthez. I have myself 
observed the following cases : 

A patient in the Salpetriere, who had been reared in a damp dwelling, 
and who was attacked with nodular rheumatism at the age of ten. 

Another in the same hospital, who had lived since her infancy in a damp 
lodge, was attacked when sixteen years old. 

Finally, a man brought up in one of those deserted quarries on the 
banks of the Loire, that so often serve as dwellings, was attacked with 
nodular rheumatism at the age of twenty, 

Partial rheumatism is — especially arthritis deformans — chiefly met with 
in individuals more advanced in life ; they frequently occur in middh 
people. Only in the young are these diseases exceptional. Yet cases have 
been seen under thirty years of age. 

As for Heberden's nodosities, we have seen that they may occur in young 
subjects, notwithstanding they especially belong to the senile period*. 

IV. — Sex. — Men are oftener attacked with acute articular rheum.: 
than women. But there is no well-marked difference in this 

Nodular rheumatism is incomparably more frequent in females |Trastour, 



THE DISEASES OF OLD AGE. 151 

Vidal) ; a convincing proof of this is afforded by a comparison between the 
inmates of Bicetre ' and the women in the wards of the Salpetriere. 

Partial rheumatism is perhaps more frequent in men; this is especially 
true for arthritis deformans. 

Heberden's nodosities seem to be more frequent in the female sex ; but 
this point is still an unsettled one. 

External causes. — First : Wet cold. — A sudden and transient impression 
of cold can only be considered as an occasional, and in no wise as a specific 
cause of rheumatism. Eisenmann's mistake must be avoided: he wrote a 
work, " Erkaltungskrankheiten " (diseases from cold), in which rheumatism 
comprises the whole pathology, or very nearly the whole. 

It is nevertheless certain that, in predisposed individuals, cold has a 
powerful tendency to evolve either acute articular rheumatism, or chronic 
rheumatism of a rapid development. 

But we are far from calling in question the influence of a prolonged resi- 
dence in a damp dwelling. On the contrary, we here recognize the most 
efficacious cause of both acute articular, and of nodular rheumatism in par- 
ticular. 

About three-fourths of the women attacked with the latter disease 
ascribe it to the prolonged influence of damp cold. When stating this to 
be an invariable condition, Beau has undoubtedly exaggerated an unques- 
tionable truth ; but certainly this cause is present in the majority of cases. 
A dwelling on the ground floor, damp, dark rooms, wet garments, the paper 
peeling from the walls — this is the condition in which we find the homes 
of most of those who are attacked with chronic rheumatism ; and besides, 
the patients have lived a long time in these sorry surroundings — for four, 
six, eight, and even ten years. In the vicinity of Chantilly there are genu- 
ine troglodytic dwellings ; they are underground excavations in the interior 
of deserted quarries. Among the unfortunates who take refuge there, a 
large number, according to Beau, become subjects of nodular rheumatism. 
We need not wonder at this ; but it must not be forgotten that, in many coun- 
tries, people still live in subterranean abodes without appearing to experience 
any great inconvenience therefrom. This is the case, for example, in certain 
provinces in the Russian Empire, notably Georgia. During the "retreat 
of the ten thousand," you know that the Greeks, when they reached Arme- 
nia, found the inhabitants of that country lodged in excavations of this kind, 
and that in the middle of the coldest winter they were most comfortable in 
these well- warmed abodes. 2 Recollect, besides, that these are cold coun- 
tries, and they only bury themselves underground to escape the severity of 
the climate. Now, we have seen that excessive cold is not at all favor- 
able, in general, to the development of rheumatism. But, in temperate 
regions, it is more difficult to escape it when such conditions of life are 
present. 

Yet the disease does not usually break forth without premonition ; there 
is oftenest a period of incubation during which patients merely experience 
vague muscular pains. Articular manifestations frequently do not develop 
until three or four years after the cause has ceased to exist. 

Second. — The influence of poverty and insufficient or improper food, 
upon the development of rheumatism, cannot be called in question : the in- 

1 Bicetre : asylum for old people and lunatics, in the neighborhood of Paris. — 
L. H. H. 

8 Xenophon: "Avafiaaig. Book iv., § 48. 



152 CLINICAL LECTURES OX 

digent in the English and Irish workhouses offer numerous instances of 
nodular rheumatism, proving certainly that the disease is an especially ple- 
beian malady, notwithstanding Hay garth's opinion to the contrary. 

Third. — Traumatic causes, as in case of gout, may determine both the 
outbursts and the primary location of the disease. 

We possess several observations where acute or chronic rheumatism 
has developed after a blow, fall, phlegmon, or whitlow, appearing first at 
the articulation nearest the injured part. 

In a woman attacked with nodular rheumatism, the disease commenced 
in the right shoulder, which had previously received a severe contu- 
sion. 

A batcher, already rheumatic, developed a phlegmon on the hand from 
a punctured wound of that member ; an attack of acute rheumatism com- 
menced in the wrist-joint, about the spot which was the principal seat of 
the phlegmonous inflammation. 

A whitlow upon one of the fingers of a woman in the Salpctric-re marked 
the commencement of a nodular rheumatism in the joints nearest to the 
diseased part. 

Partial rheumatism frequently develops after a fall or a blow ; and it is 
here difficult to determine whether it is a general disease, or a purely local 
affection secondary to the external violei. 

VI. — Pathological causes.— These often act in the same manner as exter- 
nal accidents. Acute articular rheumatism develops subsequently to a 
large number of different diseases. 

In an individual who was already rheumatic, a facial erysipelas, con- 
tracted during an epidemic of this disease, was the starting-point for acute 
articular rheumatism. This case must be distinguished from those where 
erysipelas is a part of the manifestations of the rheumatic diathesis ; for I 
could cite several instances of nodular rheumatism where the attacks of 
erysipelas have alternated with the articular symptoms. 

A few facts tend to establish the existence of a rheumatic angina ; but 
it is quite certain that a purely accidental angina has many a time be. 
starting-point of an attack of acute articular rheumatism. 

The connection between articular affections and scarlatina is well known. 
Two kinds of cases must be distinguished in thi S< »metime- 

let fever induces the outburst of an articular disease in no way distinguish- 
able from acute rheumatism ; and again, on the other hand, it is an ar- 
thritis clearly of an opposite nature, benign in the vast majority of 
according to a remark of Trousseau's, but which may become very 
and assume a purulent character, as Garrod hasobeervt d. The I 
alone deserve the name of scarlatinal arthritis ; the former belong to acute 
articular rheumatism, scarlet fever having here only played the part of a 
provocative. It is the same with blennorrhagia. 

Is there a blennorrhagic (gonorrhoeal) rheumatism ? Here is a question 
that deserves our attention for a few moments. 

In the majority of cases where articular symptoms are produced in con- 
sequence of an urethral disease, subacute arthropathies, to the nun.; 
two or three, are seen to appear in company with an iritis (BoUet) ; this is 
the classical type of blennorrhagic arthritis (gonorrhoea! rheumatism I 

But acute articular rheumatism with an endocarditis may also lx? ob- 
served to supervene upon a simple clap. A case of this kind was 
by Brandes, and Professor Lorain communicated a second to m 

Finally, chronic rheumatism attended by deformity of the joints, may 



THE DISEASES OF OLD AGE. 153 

also be occasioned by this disease (Garrod, Lorain, Broadhurst, Trous- 
seau). ! 

How can we interpret these facts? Are the manifestations in these 
cases always rheumatic ? Undoubtedly they are not. We know that the 
arthropathies which follow fevers are not always associated with this diathe- 
sis. The articular manifestations in glanders, small-pox and purulent in- 
fection (pyaemia) are clearly non-rheumatic in character. It may be, then, 
that there is a scarlatinal or blennorrhagic (gonorrhoea!) arthritis inde- 
pendent of rheumatism. I am even convinced that this is frequently the 
case ; but the articular disease that arises in such circumstances is often 
an undoubted rheumatism, developed secondarily to those affections which 
also, in certain instances, possess the inherent power of attacking the 
joints. 2 

VII. — The uterine functions. — All authors recognize the influence ex- 
erted upon the development of the various forms of rheumatism by the 
functions of the female genital apparatus. And this is true not only for 
the acute form, but also for the chronic variety of the disease. 

Indeed, the appearance of the ' catamenia, the menopause, pregnancy, 
delivery, the puerperal state, and lactation, are causes which in women ex- 
ert a powerful influence over the development of articular rheumatism. 

And concerning this, let us enter somewhat into details. 

Chlorosis is a base on which the articular manifestations of rheumatism 
are very apt to develop. Musgrave cites several cases of arthritis ex chlorosi 
that evidently belong to nodular rheumatism. The happy results arising 
from the administration of iron are aflirmed in many cases of this kind. 

It is well known that the menopause is frequently accompanied by a con- 
dition analogous to that of chlorosis in young girls, and it is likewise a 
settled fact that chronic rheumatism often develops at this period of life. 

Pseudo-membranous dysmenorrhoea has been described by Todd among 
the diseases that accompany nodular rheumatism. It is perhaps not un- 
interesting to observe in this connection that dysmenorrhoea frequently 
accompanies the eruptions (erythema nodosum, for example) that are oc- 
casionally met with in acute and subacute rheumatism. In individuals 
already suffering from the malady, each menstruation has produced an 
exacerbation of the pain. The abrupt suppression of the menses, follow- 
ing upon some intense emotion, has occasionally been the starting-point 
for nodular rheumatism. 

Pregnancy is likewise one of the causes of this disease. In a work 
which my colleague, Dr. Lorain, was kind enough to send me, are recorded 
several examples where acute, or subacute articular rheumatism, has ap- 
peared in women who were with child. In my thesis I have reported sev- 
eral cases of nodular rheumatism which developed under the same condi- 
tions ; Todd had already noted the same coincidence. 

It is not rare to see an isolated arthritis appear during pregnancy, and 
become general after delivery. Besides, acute rheumatism itself has been 
seen to occur during pregnancy (Chomel and Requin, Todd). It must not 
be forgotten, however, that multiple purulent arthropathies may be de- 

1 Garrod on Gout, p. 545. Broadhurst iu Reynolds' System of Medicine. Vol. i. , 
p. 920. Trousseau: Clin. Med. de l'Hotel-Dieu. Vol. iii., p. 375. Professor Lorain's 
case was a verbal communication. 

2 See a discussion on this subject, occurring in the Medical Society of the Hospi- 
tals : Union M dicale, December 23, 1866, and March 5, 1867. 



154 CLINICAL LECTUEES ON 

veloped in confinement. "We think that these cases have been wrongly- 
designated by the name puerperal rheumatism. 

Another condition in which the various forms of rheumatism — sub- 
acute and chronic especially — may present themselves, is lactation, particu- 
larly when this is long-continued (Lorain, Garrod). 1 

It would be interesting to compare this etiology with that of gout, and 
exhibit the differences between the two ; but time presses, and we must 
content ourselves with a general view of the question. 

Generally speaking, it is true that the causes of gout are associated 
with comfort, excesses, and good cheer ; in the same general way, rheuma- 
tism, especially the chronic form, has poverty, damp cold, insufficient food, 
and debilitating influences of various kinds, as its etiological factors. 

But the contrast becomes } r et more striking if we compare the diseases 
usually associated with gout, with those habitually accompanying rheuma- 
tism. 

On the one hand we find diabetes, 2 obesity, and gravel, 3 whose rela- 
tionship with gout we have already proved (pp. 75 to 79), and whose ap- 
pearance in rheumatism is rarely obseiwed ; on the other hand, scrofula,* 
phthisis, and cancerous affections, 6 of frequent occurrence in chronic rheu- 
matism, are very uncommon in gout. 

Here, certainly, are differences between the two diatheses from an etio- 
logical standpoint ; and yet, in spite of these great diversities which sepa- 
rate them, and which we have endeavored to make clear and prominent, they 
still offer remarkable analogies ; indeed, they have frequently been con- 
founded. And even when they have been differentiated, they must neverthe- 
less be approximated in every good nosological classification. 

It is certain, moreover, that a relation capable of being demonstr 
in many ways, closely associates rheumatism and gout. 

They sometimes appear- in the same individual, who presents at the 
same time the lesions of both gout and chronic articular rheumatism. 

Again, acute articular rheumatism cccurs in a patient during his youth, 
and then gout is developed at the usual time therefor. 8 

1 On Gout, p. 5G8. 

2 In two hundred and twenty-five cases of diabetes. Griesinger, in his Studies of 
Diabetes, only twice found acute articular rheumatism. I do not think that diabetes 
has ever been observed as a complication of chronic rheumatism. 

3 1 have seen uric acid gravel occurring in a woman with nodular rheumatism ; but 
an examination of the blood at several different times, in this case, never revealed an 
excess of uric acid therein. 

4 Scrofula very frequently appears among the antecedents qf individuals attacked 
with progressive chronic rheumatism. It is very common to see those patient- 
specific cicatrices of the neck. I could mention several cases where wonun who, 
during their youth, have had white swellings, and in whom, at a later period, nodu- 
lar rheumatism has developed. In one hundred and nineteen cases of nodular rheu- 
matism, Fuller (loc. cit, p. 334) states that twenty-three {ox one -fifth of the whole) 
had mother, father, or collateral relations presenting evident signs of phthisis pulmo- 
nale. This disease, I can avow, often carries off patients afflicted with nodular rheu- 
matism ; and in such cases it seems to me that the phthisis was remarkable for its 
slow development. In individuals attacked with acute rheumatism, phthisis is rare 
(Wunderlich, Hamernjk). Still, a coincidence of these two diseases Dan- 

joy, who has directed attention to this point, thinks that the disease is then modified 
in its development — that it is retarded. 

6 1 have often convinced myself, in the Salpetriere, that the coincidence of Heber- 
den's nodosities either with cancer of the breast or cancer of the uterus, is not an ex- 
ceptional circumstance. 

6 See Baillou on this subject, vol. iv., p. 415. Was it this that made Junek.r 
rheumatkmus arthritidem online u/ttecedit? 



THE DISEASES OF OLD AGE. 155 

Finally, a relationship may be established between them by means of 
heredity. Acute articular rheumatism occurs frequently in the children of 
the gouty (Heberden, Fuller, Todd). The children of the rheumatic often 
become subjects of the gout (Fuller). Indeed, heredity may show itself in 
the collateral branches : I have myself seen nodular rheumatism appear in 
a woman whose brother was gouty. 

Do these relations, apparently so close, prove the identity of these two 
diseases ? No, certainly not : at the utmost, let us admit the existence of 
a common foundation, a common basis, an articular predisposition, an arthritic 
condition, whence both affections take their origin. 



156 CLINICAL LECTURES ON 



LECTURE XVIII. 

TREATMENT OF GOUT AND CHRONIC ARTICULAR RHEUMATISM. 

Summary. — General Considerations Concerning the Treatment of Gout— Treatment of 
the Attacks or Paroxysms — The Expectant Plan — Quack rtemedies- -Colchicum — 
Advantages and Disadvantages of this Agent — Rules which should Govern its Em- 
ployment — Narcotics : Hyoscyamus and Opium — Sulphate of Quinia — Iodide of 
Potassium — Tincture of Guaiacum — Topical Remedies — Leeches- M. xa 

— Treatment of the Constitutional Condition — Alkalies — Their Various Properties 
— Sodium. Potassium, Lithium — Action of these Drugs '.Ikaies are 

Contraindicated — Mineral Waters — Tonics and Stomachics — Treatment of the 
Local Affection : Chalk-Stones and Rigidity of Joints — Treatment of Abnormal 
Gout — Dietetic Regimen. 

Treatment of Chronic Articular Rheumatism — Unsatisfactory State of our 
Knowledge upon this Subject — Treatment of the Act. .—Opium, 

Sulphate of Quinia, Bloodletting — Alkalies — Tincture of Iodine — Arsenic Inter- 
nally and Externally — Tincture of Guaiacum— Iodide of Potassium — Iron, Cod- 
Liver Oil — Blisters, Revulsives — Mineral Waters— Medical Art Powerless in the 
Majority of Cases. 

Gentlemen : — "We reach, to-day, the last part of our course. We have 

postponed the treatment of gout until the close of our lectui - to be 

able to compare it with that of chronic articular rheumatism. And this 
question we shall now discuss. 



Treatment of Gout. 

I. — General considerations. — Gout is a constitutional, hereditary dis- 
ease, and primarily chronic, notwithstanding its acute manifestations. 

But gout is also at times an acquired affection, now arising because of 
errors in diet, and now from other causes ; this is a kind of spontaneous 
generation. 

It may be concluded that hygienic influences are here placed in the first 
rank, and that therapeutical agents only occupy second place. Indeed, ex- 
perience has long since demonstrated the truth of this statement 

We do not mean to say that the disease is radically incurable : exam- 
ples of spontaneous cure are on record, but our art has not yel been able 
to reproduce with certaiuty the processes of nature. 

The proper means do exist, however, for lessening the effects of the dis- 
ease, and to avert its paroxysms ; upon these, collectively, rests our I 
ment of the constitutional condition during the interval between the at- 
tacks or fits. 

But we have a humbler, although more useful mission to fulfil. The 
periodical manifestations — the paroxysms— of both acute and chronic gout, 
are accompanied by terrible and often unbearable suffering. 

Can we suppress these crises of pain, or at least diminish their iute: 



THE DISEASES OF OLD AGE. 15? 

and shorten their duration ? This constitutes the treatment of a paroxysm 
of gout. Let us first consider the latter point. 

II. — Treatment of a paroxysm of acute or chronic gout. — This is a ques- 
tion of treatment which is in great measure palliative in character. A few 
physicians have even gone so far as to proscribe all means of relief as dan- 
gerous and pernicious. This is Sydenham's school, which assumes the tel- 
eological standpoint ; this great teacher says : " Dolor acerrimum naturce 
pharmacum." " Gout is gout's best remedy," said Mead ; and Cullen pre- 
scribed "patience and flannel." 

The partisans of the expectant plan base their belief on the inefficacy of 
known remedies, on the danger of their application, and especially on the 
relief experienced by the patient after the attack or fit. But to these argu- 
ments it may be answered that the inertness of capable men opens the way 
to quacks. The physician leaves a gouty patient — the quack seizes upon 
him. They appear with remedies which give almost instantaneous relief, 
and, if they sometimes induce grave symptoms, are yet often free from all 
real danger. Such are Keynold's elixir, Lavihe's anti-gout liquid, Audu- 
ran's wine, Lartigue's pills, etc., etc. 

Now, I believe it is well established that all these so-called specifics owe 
most of their efficacy to the presence of colchicum. And thus it is the part of 
the physician to attentively study the therapeutic properties of this formid- 
able agent, which sometimes affords the patient the greatest relief without 
any harm, and again induces serious symptoms that may end in death. No 
one, indeed — not even its bitterest enemy, denies its potency. It causes the 
gouty inflammation and the terrible pain that accompanies it to disappear as 
if by magic. 

In this respect its action is nearly similar to that of quinine in intermit- 
tent fevers ; and here, again, is one of the differential points between gout 
and articular rheumatism. In the acute form of the latter disease, Professor 
Monneret has already shown that colchicum is useless ; and in the different 
forms of chronic rheumatism, I have assured myself that this drug possesses 
no advantages whatever. 

How does it act in cases of gout ? Since the sixth century of the Chris- 
tian era, the ancients were acquainted with the advantages and disadvan- 
tages of colchicum. Alexander of Tralles tells us that, in his time, it was 
given only to those who were busy with their work and had no time to be 
sick. Demetrius Pepagomnenus, who lived about the year 1200, calls it 
Theriaca artieulorum. 

But the colchicum of the ancients is not our colchicum. They used the 
hermodactyl l (colchicum variegatum, Planchon); to-day we use the colchicum 
autumnale. 

Fallen into neglect, this drug was again brought into notice and use by 
the effects of Husson's remedy. Everard Home extolled colchicum, which 
Storch had already brought into vogue for other diseases than gout. Later 
on its effects were carefully studied by Wandt, Halford, Watson, and" 
Garrod. 

All parts of the plant are used — bulb, seeds, and flowers. It is admin- 
istered as the extract, wine, or tincture. The wine of colchicum-bulbs is 
administered in doses of from two to six grammes, twice or four times dur- 
ing the twenty-four hours (thirty minims to a fluid drachm and a half); the 

1 Hermodactyl: Mercury finger. — L. H. H. 



158 CLINICAL LECTURES ON 

acetic extract is prescribed in doses varying from five to fifteen centi- 
grammes (gr. j.-ij., nearly). 

A word concerning the physiological effects of this drug. In large 
doses it causes : 

First. — More or less serious gastro- enteric phenomena. 

Second. — A marked sedation or depression of the circulatory system, 
with a tendency toward algidity and slowing of the pulse. 

Third. — Finally, nervous symptoms and a peculiar kind of drunkenness. 

In small doses it merely creates slight nausea and a moderate retarda- 
tion of the circulation. 

Now, it is in small doses, at least when it is tolerated, that it acts favor- 
ably in gout ; in its administration we must avoid the inflammatory phe- 
nomena on the part of the digestive tract ; indeed, its action seems to be 
the more efficacious the less pronounced are its operative effects {effete 
visibles). 

Its specific action is shown in the disappearance of the gouty inflamma- 
tion and the pain that accompanies it ; resolution occurs, as if by magic, 
at the end of eight to fourteen hours. It is far from possessing the same 
degree of influence over other inflammations and the various forms of ar- 
ticular rheumatism, as we have previously intimated. 

What is its mode of action ? This is a question which has not yet been 
solved. No effects have been attributed to the elimination of uric acid ; 
this theory, upheld by Chelius, Maclagen, and Gregory, is combated by 
Garrod, Bocker, and Hammond. The latter base their opinion upon care- 
ful urinary analyses that seem to leave no opening for criticism. 

Its sedative action upon the circulation has been adduced as a reason ; 
but this is certainly not the secret, since it does not act in the same way in 
other inflammations. 

Its purgative action is also out of the question, for its specific proper- 
ties can manifest themselves without the occurrence of any intestinal 
evacuation. 

We cannot, finally, ascribe it to its narcotic power, for even in this it 
presents an effect peculiar to gout. 

Be this as it may, its efficacy is beyond all question. But we must look 
upon the dark side of the picture, and see what dangers the administration 
of colchicum involves. 

It is beyond dispute that, when imprudently given, very serious results 
may be the consequence. What are the rules, then, that should govern 
its administration? 

First. — Gout is a retrocedent disease, as we have previously proved. 
If, then, you abruptly suppress an attack or paroxysm, visceral derange- 
ments may be developed ; but no such danger is to be dreaded when 
small doses are exhibited. Besides, colchicum ought not to be administered 
immediately upon the outbreak of the attack (Halford, Troon 
days should elapse before beginning its use. Finallv, we should fear its 
irritating action upon the digestive tract ; and this is another reason for 
not prescribing large doses. 

Second, — Not only must we avoid the exhibition of large doses, but it 
is also necessary to suspend the drug for a time, since, in certain pa: 
its effects appeal* to be cumulative. Under such circumstances <ve may 
have reason to apprehend a sudden impression upon the nervous system ; 
indeed, I am disposed to think that many cases where gout has appaivntly 
retroceded under the influence of colchicum, and induced death, are noth- 
ing but cases of colchicum-poisoning (Potton). 



THE DISEASES OF OLD AGE. 159 

Third. — We must not accustom the patient to the use of this drug, for, 
in that case, he is obliged to take ever-increasing doses. There are colchi- 
cum-drinkers as well as opium-eaters and drunkards (Todd). Under these 
conditions a more or less profound change in the organism may be in- 
duced, and, on account of this influence, gout may pass into the atonic 
state. 

Fourth. — Colchicum ought not to be administered in asthenic gout, but 
it may, nevertheless, be given with advantage in certain paroxysms of 
chronic gout. It is said to occasionally prolong the attack ; but frequently, 
on the other hand, it seems to shorten the duration of the disease (Goupil, 
de Rennes). 

Fifth. — The action of colchicum must be aided by a proper regimen 
(diet, rest in bed) and by adjuvants ; salts of potassium and lithium should 
preferably be employed. Indeed, purgatives are often given with benefit ; 
but the mercurials are contraindicated, experience proving that they have 
serious disadvantages. 

There are cases in which colchicum may not be administered. But, 
despite this, the practitioner is not completely helpless. There are still 
other means which may be resorted to with success. 

During an acute attack we may give, internally, the narcotics, especially 
hyoscyamus. Opium may also be prescribed, but it is disadvantageous on 
account of diminishing the secretions, and in this way hindering the regu- 
lar development of the disease. It also induces, in certain individuals, ef- 
fects which are out of all proportion to the dose exhibited. I have often 
seen these drugs (narcotics) cause distressing cerebral phenomena, and 
even induce ursemic symptoms in those who had pre-existing renal disease. 
We should be especially apprehensive of occurrences of this kind when gout 
has been of long standing, and the lesions of gouty kidney are already well- 
marked. 

Todd records a very remarkable case of this kind. 

The sulphate of quinine may likewise be administered with some chance 
of success ; but its action in gout is far from being as efficacious as in acute 
rheumatism. 

In the exacerbations of the chronic stage, sulphate of quinine is again 
useful. Apart from the attack, the more or less permanent pains that are 
located in the joints are sometimes successfully combated by the iodide of 
potassium and the ammoniated tincture of guaiacum (twenty to forty drops 
a day). 

Externally we may employ various topical remedies during the attack. 
Cold water is frequently applied to the diseased joints ; but, as we have 
already demonstrated to you, nothing is more likely to induce retrocessions. 

Leeches, loco dolenti, used to be prescribed ; but this is abandoned at 
the present day, since it has been observed that after their use the joints 
resume with difficulty their normal mobility. Narcotics, on the other hand, 
and atropine especially, may be applied to the diseased articulation with 
advantage. 

Blisters are often useful, both in acute and in subacute cases. A small 
blister, not exceeding in size that of a franc (our twenty-cent coin), when ap- 
plied to the red and swollen joint, frequently acts in the most efficient man- 
ner in the midst of a paroxysm (Todd and Cartwright). I have occasionally 
made use of this remedy with excellent results. 

Finally, moxa is a remedy sometimes employed in this disease. We 
may quote in this connection the case of Chancellor William Temple, who 
himself applied this remedy every time he suffered an attack of the gout. 



160 CLINICAL LECTURES ON 

TTT — Treatment of the constitutional condition. — The chief indication in 
this instance is not only to modify the blood-condition, but rather to stop 
the formation of uric acid in excess. This would be an ideal treatment ; 
but how can we make it a reality ? We can scarcely proceed in this man- 
ner, except in fighting a dyspepsia, where we prevent an attack by confining 
the patient to an appropriate diet. 

Still, once uric acid has formed in the blood, we may combat the effects 
arising from its presence in excessive amount. The excretion of this pro- 
duct by way of the kidneys must be favored, and remedies possess, for this 
purpose, a powerful action. We should prevent deposits of urate of soda 
from forming in the tissues ; and when these already exist, we must en- 
deavor to dissolve them. 

Empiricism has made known a group of agents that answered these in- 
dications long before the discovery of uric acid. These are the alkalies ; 
and under this head are comprised : 

First. — The alkali metals (sodium, potassium, lithium) and their carbo- 
nates. They have a marked effect in neutralizing the acidity of the 
stomach. 

Second. — The organic salts (citrates, tartrates, etc.) having an alkaline 



Third. — The phosphates of soda and ammonia, having on alkaline reac- 
tion, and a special action upon the urinary secretion. 

It would be an error to suppose that all the alkalies may be indiffer- 
ently substituted for one another. Let us recall, in this connection, the 
experiments of Claude Bernard and Grandeau. subsequently repeat 
Guttman. 1 These investigators found that a gramme (15.4 <jnmt,<> of 
of potassium, injected into the vein of a medium-sized enough to 

cause its death ; twenty centigrammes (a little over tlir> 
cient to kill a rabbit. To obtain the same results with a sodium salt, at 
least three times as strong a do» essarv. 

Let us now consider the special action of each of these substances taken 
separately, and, beginning with the two bases which are most commonly 
administered, let us institute a comparison between Hum. 

The salts of potassium possess a diuretic action : this fart has been 
thoroughly proved by Mischerlich. The salts of sodium do not | 
marked a diuretic action. 

The solvent action of potassa upon uric acid is much more energetic 
than that of soda. It is well known that the urate of potash is much more 
soluble than the urate of soda. Besides, when a cartilage inerusted with 
urate of soda is plunged into a solution of carbonate of ] u ob- 

serve a rapid, solvent.action ; if, on the other hand, it be placed in a solution 
of carbonate of soda, you scarcely obtain any appreciable effect in the same 
period of time. 

Thus, a priori, potassa is more efficacious than sod 
base is useful in those cases of gout where there is live: rding 

to Garrod. 

But there is a substance little known even at the present day. namely, 
lithium, which seems in every respect to prevail over potash and soda. 

This metal, discovered by Arfwedson in 181" in many min- 



1 Berliner klin. YVochen. 1 965. 

2 Previous to the publication of Garrod's tre.itise. Pr. Galtn r- 

attention to the much greater intensity of pota solving Mtii red to 

that of soda, in the treatment of gout. *De la Goutte. p. 112. ThtW de 1 



THE DISEASES OF OLD AGE. 161 

eral waters — in Carlsbad, Vals, Vichy, Baden-Baden, and Weilbach, in which 
latter town there is a newly discovered spring that is called " Natrolithion- 
quelle" (sodium-lithium spring), and contains a large proportion of this 
substance. 

Spectrum analysis enabled Bunsen and KirchofT to determine its pres- 
ence in human milk and blood. It is not, then, a substance foreign to our 
organism; and if potassa exists in the blood-corpuscles, and soda in the 
serum, lithium is likewise found, though in very minute quantity, in the 
nourishing fluid of the economy. 

This new agent answers all the indications we have enumerated. It has 
a well-marked diuretic action ; it makes the urine strongly alkaline, and 
dissolves uric acid energetically. In this respect it is much superior to 
potassa, for the urate of lithia is the most soluble of urates. 

Garrod performed the following experiment : into three solutions, the 
first containing five centigrammes of carbonate of lithia {four-fifths of a 
grain) ; the second, five centigrammes of carbonate of potassa ; and the 
third, five centigrammes of carbonate of soda, to thirty grammes (very 
nearly one ounce) of water, — into each of these were put pieces of the same 
cartilage impregnated ivith urate of soda ; at the end of forty-eight hours 
the lithium had completely dissolved it ; the potash had only slightly acted 
upon it ; and the soda had given an absolutely negative result. 

Urate of lithia is clearly, then, the most soluble of all the urates. 

"What is the mode of action of the alkalies ujDon the blood in gout? 
They have no power to lessen the formation of uric acid ; nor can they dis- 
solve it, as various observers have supposed, for it exists in the form of urate 
of soda. But in rendering the tissues alkaline, they may hinder the forma- 
tion of deposits ; besides, the carbonates of lithia and potassa can dissolve 
existing deposits, a result the carbonate of soda cannot effect. Beyond 
this their influence would be useless, were it not for the fact that they pos- 
sess at the same time a diuretic action. 

This is what theory says ; and now let lis question therapeutical ex- 
perimentation. 

The alkalies, especially potash and lithia, when administered in small, 
in very dilute doses — for the action of water is most efficacious, and particu- 
larly when exhibited for a long period of time — possess a remarkable ac- 
tion in cases of gout. They postpone the paroxysms, they sometimes dis- 
solve and diminish the depositions that have already formed, and give more 
mobility to the joints. 

Carbonate of lithia is administered in doses varying from twenty-five to 
thirty centigrammes (nearly gr. iijss — gr. ivss.) for the twenty-four hours. 
I have prescribed it myself in forty centigrammes doses (six-grain doses) 
without producing any unpleasant effects on the stomach. 

Strieker l has succeeded in causing tophaceous deposits in a woman to 
disappear, by giving her an artificial imitation of the Weilbach water, made 
according to the following formula : 

Water charged with carbonic acid § xvj. 

Bicarbonate of soda gr. iijss. 

Carbonate of lithia gr. jss. 

This quantity represents the dose to be taken each day. 
Schutzenberger has advised the use of water charged with protoxide of 

1 Virchow's Archiv. Bd. xxxv. 
11 



162 CLINICAL LECTURES ON 

nitrogen (nitrons oxide, monoxide of nitrogen) containing a gramme fgr. 
xvss.) to the litre (2.1 pints). 

Prescribing the alkalies in this way, we may be enabled to have them 
tolerated for several months. No serious inconvenience arises when the 
limits are the doses we have just mentioned. 

It is also necessary to know the cases where the alkaline treatment is 
applicable. It is formally contraindicated : 

First. — In individuals who are advanced in years. 

Second. — In those whose kidneys, being more or less deranged, no longer 
have the power of elimination. 

Third. — In those with whom alkalies disagree on account of some pecu- 
liar idiosyncrasy. 

It is perhaps not ill-timed to state, in this connection, that the dangers 
of saturation of the blood with alkalies is much exaggerated, at le 
far as bicarbonate of soda is concerned. My own personal experience is con- 
trary to the general, accredited views in this regard. To individuals suf- 
fering with chronic rheumatism I have frequently given apparently enor- 
mous doses of bicarbonate of soda, from twenty to thirty grammes (a little 
over 3 vijss.) in twenty-four hours, and sometimes for several months at a 
time ; and in such cases I have never seen either profound anaemia, <;:- 
tion of the blood, or multiple hemorrhages, which might hare been antici- 
pated according to the generally received notions on this subject. But, with 
regard to potassa in large doses, I have not had the opportunity to directly 
study its effects, and I am completely ignorant of the results it may bring 
about. 

There remain a few words to be said about mineral waters in the treat- 
ment of gout ; this naturally complements the study to which we have just 
devoted our attention. 

Generally speaking, waters loaded with saline ingredients precipitate the 
attacks and induce the crisis that should be averted. Certainly this 
absolute contraindication, but it is a point that the physician ought always 
bear in mind, so as never to be taken unawares by the i 
ment he has prescribed. 

Mineral waters are, in general, contraindicated in patients suffering or- 
ganic lesions of heart or kidneys. 

Concerning alkaline springs (Vals, Vichy, Carlsbad. etcA they seem to 
possess advantages at the commencement of the disease in the r 
especially in those who have hepatic affections. But they have no power 
to dissolve the tophi, and they are of little benefit in chronic gout, al 
when there is no dyspepsia. 

Sulphur saline (Aix-la-Chapelle) or simple saline waters (Wiesbaden) 
are best in the torpid fomi in atonic cases. 

There are indifferent waters, to make use of an expression sanctioned by 
German usage, whose mineral constituents are in such fiery small j . 
tion (apeines chargies), that the real active principle is the water imbibed 
in large quantities. In this class we may place, from our standpoint at 
least, the waters of Wildbad, Toplitz, Gastein. Bath, Buxton, and 
ville. They are frequently very beneficial in chronic gout. 1 
instances we have seen Contrexeville water administered in case of a 
long-standing gout with tophaceous deposits, and the result seemed most 
favorable. 

Finally, chalybeate waters (Pymiont, Schwalbach. Bj 
ful in cases where iron is indicated. 

We shall limit ourselves to this brief statement of the action of mil 



THE DISEASES OF OLD AGE. 163 

waters in the treatment of gout. If we were to give a critical estimate of 
all that has been written upon the subject both by avowed partisans of the 
waters, and by their adversaries, we could readily fill a volume. It is 
enough to say, in a general way, that on both sides there has been much 
exaggeration. 

Let us discuss for a moment the tonics and stomachics. They possess an 
indirect action upon gout by modifying the condition of the stomach, by 
combating atony, and by reviving the strength. They are very useful in 
cases of asthenic gout. 

The decoction of common ash (Fraxinus excelsior) leaves has been used 
with much success ; it has been recommended by Pouget and Peyraud. It 
is prepared in the following way : 

Leaves of Fraxinus excelsior (common ash) § i. 

Water Oij. 

Boil for ten miuutes. 

Garrod has employed this infusion * with a certain degree of success. 
Cinchona has likewise been used with advantage along with gentian, 
which is one of the principal ingredients of Portland powders. 

IV. — Treatment of the local disease, of tophi (chalk-stones), and rigidity of 
joints. — We should prescribe exercise for those suffering with gout, as it 
tends to diminish the rigidity ; this Sydenham has already demonstrated. 
To dissolve the tophi, it has been advised to make lotions of potash and 
lithia ; and when the concretions are of small size and superficially seated, 
the skin may be punctured in order to extract them, especially when they 
are semifluid. But generally, when they are large, hard, and deep-seated, 
all operative interference is forbidden, since it frequently happens that ul- 
cers result whose cicatrization is very difficult. Besides, it must not be for- 
gotten that we may have a dangerous erysipelas resulting from the slightest 
wound in gouty patients who are attacked with kidney disease, and espe- 
cially in diabetic individuals. 

When ulcers form spontaneously, the rule is to avoid intermeddling. 

V. — Treatment of anomalous gout. — It is a generally accepted and recog- 
nized fact that when gout has retroceded, especially to the stomach, we 
must have recourse to revulsives upon the articulations. Without question- 
ing their utility, let me observe that there are very few authentic records 
sufficient to establish the efficiency of this mode of treatment in bringing 
back a gouty inflammation to the joints. Stimulants, cordials, and brandy 
are often, on the other hand, followed by readily appreciable results, and 
experience seems to have demonstrated their utility. 

When it is a case of misplaced gout (megrim, ophthalmia, etc.) colchi- 
cum, administered in small doses, is indicated, according to Watson, Hol- 
land, and some other authors. But this is a question that, to us, seems far 
from being settled. 

VI. — Dietetic regimen. — A gouty individual should take plenty of exer- 
cise : he should let his diet be a sober one, but in no way exaggerated, for 

1 Tanner states that the " dose is a tumblerful of a weak infusion of F. excelsior 
(one ounce of the leaves infused into a pint and a half of water), taken on an empty 
stomach, night and morning." — L. H. H. m 



164 . CLINICAL LECTURES ON 

otherwise the development of atonic gout would be favored. Strong beer 
and wines rich in alcohol must be rigorously interdicted, but he may drink 
light beer, moselle, and claret. He should travel ; change of climate is fre- 
quently beneficial, according to the English physicians, who recommend 
India, Egypt, Malta, and other localities in the hot countries ; but such a 
change does not at all dispense with the observance of a proper regimen. 

Finally, mental hygiene must be regulated : the irritation so natural to 
this class of patients must be combated ; sadness, despondency, and the 
preoccuj)ation and excess of intellectual labor, must be avoided. 



Treat:\ien t t of Cheonic Articular Rheumatism. 

We have heretofore entered into so many details, that the latter part of 
this lecture must necessarily be abridged. It may be said that the treat- 
ment of chronic articular rheumatism is even less efficacious than that of 
gout ; we are still less advanced in this respect, arid we have not even 
colchicum with which to combat the most } mptoms of the disease. 

In cases where acute phenomena supervene, the indications are almost 
the same as in acute articular rheumatism. Opium, sulphate of quinine, 
local bloodlettings, etc., are sometimes prescribed with successful results ; 
but, in the great majority of cases, we are powerless to check the progres- 
sive course of the malady. 

Large doses of alkalies, according to Garrod, are here much less pow- 
erful than in acute articular rheumatism. Still, this is the treatment in 
which, from my own personal experience, I have the most confidence, when 
in addition, quinine is employed. Besides, this is a purely empirical rem- 
edy. I have frequently prescribed from thirty to forty grammes ( I 7.7 to 
3 j. 3ij.) of carbonate of soda a day, during several weeks, with advanta- 
geous results. And, asl said when speaking of gout. 1 I i u the 
production of any symptoms of dissolution of the hh><><{ ; on the contrary, 
the patients often seem to have a certain teudenc; ater. By 
means of this treatment we are enabled to at least procure them a a 
amount of relief during the febrile exacerbations of the dia 

Tincture of iodine, internally, has been highly praised by Professor 
Lasegue. The dose has been steadily increased from eight to ten d] 
day to five or six grammes ( 3 j. gr. xviij. to " jss.), given during meals, the 
excipient being a little sugared water, or better, a glasf oish wine. 

The drug should be continued for several weeks, and, if necessary, foi 
eral months. Its infiuence has never given rise to any symptoms of iodine 
poisoning. ' 

Arsenic has been employed by Bardsley and Jenkinson, Begbie. Fuller 
and Garrod of England, and by Beau and Gueneau de Mussy of France. 2 
Bardsley has administered this drug especially in eases oi chronic rheuma- 
tism located in the larger joints ; but the other writers, whose nam< - 
given above, have exhibited it particularly in cases of nodular rheumatism. 
I have myself tried this remedy in the SalpJtriere. and, like Garrod. have 
occasionally seen arsenic produce marked amelioration, and again result in 
complete failure. I think, however, that I am justified in affirming that 

1 Arch. gen. de Med. Vol. ii. 1850. 

2 Bardsley: Medical Reports. London. 1807. Kellie : RdL 

Vol. iii. 1S0S. J. Begbie (in same journal), No. 35. May, 1858. Poller: On 
matisni. Second edition. Loudon. 1^00. Gueneau de Mussy rapeu- 

tique. Vol. lxvii., p. 2L lSb'L Beau: Gaz. des Hdpitaux. July 10, 1- 



THE DISEASES OF OLD AGE. 165 

arsenic is without any effect — indeed, is harmful even, in the most inveterate 
cases of nodular rheumatism, and when the disease has set in late in life. 

One of the first effects of its administration is frequently to reawaken the 
pains, and to make them much worse in those joints usually and most seri- 
ously implicated. Indeed, pain and swelling sometimes manifest them- 
selves in places where they did not previously exist, even compelling us to 
suspend for a time our treatment. Generally, however, tolerance is estab- 
lished at the end of a few days, and then the dose may be steadily increased. 
It is advantageous, in my opinion at least, to exhibit arsenic in the form 
of Fowler's solution in doses of from two to six drops, and this a short time 
after meals, according to the method in vogue in England. 

In France, while arsenic has been prescribed internally, it has likewise 
been employed in the form of baths by Gueneau de Mussy and Beau. In 
1861, I made use of this method of treatment in the Lariboisiere Hospital. 
Ducom, the head pharmacist of that institution, very kindly undertook the 
analysis of the urine of those whom I had submitted to this mode of treat- 
ment, either internally or externally. In the first case, arsenic was found 
in the urine after a short lapse of time ; in the second the results were in 
all cases negative. Thus, it seems probable that these two methods do not 
act in the same way upon the organism, even if we admit that both are 
equally efficient in combating the disease — a statement that I am inclined 
to doubt. 

There is another drug which I have employed in cases of this kind, with 
results analogous to those from arsenic. It is the ammoniated tincture of 
guaiacum, which first produces an exacerbation of the local symptoms, and 
then marked relief ; the mobility of the joints reappears, and occasionally, 
after a certain time, the patient experiences evident amelioration. 

The iodide of potassium has sometimes been successfully prescribed in 
cases of chronic rheumatism. 

In chlorotic and debilitated individuals, iron and cod-liver oil may be 
indirectly useful by modifying the general bodily condition. 

The local remedies most frequently made use of are blisters, painting 
with tincture of iodine, and actual cautery (red-hot points). The latter is 
especially useful in the partial form of chronic rheumatism. 

Concerning mineral waters, Mont-Dore, Lamalou l'Ancien, Vals, Neris 
and Plombieres have all been prescribed ; most of these waters contain 
arsenic ; can it be that the efficacy ascribed them is due to this circum- 
stance ? 

We are far from having exhausted the long list of remedies that have 
been advocated for chronic rheumatism by various authors, or that we our- 
selves have tried. We have endeavored to bring prominently forward those 
therapeutical agents that to us seem possessed of the highest degree of 
efficacy ; but still we must acknowledge that chronic rheumatism is a 
disease which, in the majority of cases, baffles all the resources of medicine. 



166 CLINICAL LECTURES ON 



APPENDIX. 

CLINICAL IMPORTANCE OF THERMOMETRY IN OLD AGE. 1 



LECTURE XIX. 

Summary. — Importance of Clinical Thermometry in General — Its Application to Se- 
nile Pathology — Central Algidity — Normal Temperature in Old Age— Axillary and 
Rectal Thermometry — Bodily Temperature of Old People in Pathological Condi- 
tions — Extreme Limits of the Central Temperature — Low. Medium. \<w\ High Feb- 
rile Temperatures — Danger from High Temperatures \vh< n Continued for any 
Length of Time — Rational Explanation of the Danger Presented by this < » 
rence — Physiological Experiments— Danger from Lowering of the Temperature.* 

Gentlemen : — In our previous meetings I have endeavored to make 
prominent the very remarkable characteristics which give a special, a 
unique aspect to senile pathology. I have particularly sought to 
bold relief, by means of striking examples, the assistance which medicine 
may derive from the methodical use of the thermometer from the triple 
standpoint of diagnosis, prognosis and treatment in oases when 
has to penetrate the many dangers that beset it at the clinic of the 
To-day I purpose to continue this study, and supplement it with sonu 
developments which, on account of the too concise form of my first lec- 
tures, I was not then enabled to present to you. 

It is no longer necessary, at the present day, to expend much eloqu- 
in defence of clinical thermometry; this method has forced its own way. 
and has extended almost everywhere. It was not exactly the same, how- 
ever, when, in 18G3, we applied clinical thermometry in the ordinary 
practice ; still, perhaps, something remains yet to be done in order to 
demonstrate that this method does not belong exdnsively to scientific 
investigation. 

As you know, clinical thermometry is a physical means of exploration 
analogous to auscultation and percussion; but while the lat: 
ble to local lesions especially, the former has to do with the fundai. 
phenomena of the febrile state, whose measure, so to speak, it is. 3 "What 
then is fever? All authors to-day answer this question by I letini- 

tion: color proeter naturam. Indeed, all the other symptoms of fever may 

1 Lectures delivered by J. M. Charcot, in the Salrvtriere. 1893 I xix . 

xx., and xxi., are i., ii., and iii. of the Appendix, renumbered to avoid confusion. — 
L. H. H.) 

-These lectures were collected together by Dr. Joffry, at that tii: .a in- 

terne in Professor Charcot's service. 

8 Wunderlich : Verhalten der Eigenwarme in Krankheiten. I -08. 



THE DISEASES OP OLD AGE. 167 

be wanting, but the mere elevation of animal heat remains the constant, 
the characteristic, the obligatory occurrence. 

This is the law, the general law, and one from which old age itself is not 
exempt. For, gentlemen, that isolation of the organs, that want" of gen- 
eral reaction which I have described to you in the preceding lectures, is 
only apparent, not real. As in children and adults, fever, or at least an ele- 
vation of the bodily temperature, occurs in old people, and frequently at- 
tains almost the same degree of intensity ; but in the latter, much oftener 
than in the former, it may remain latent — that is to say, it may not be re- 
vealed by the external phenomena which usually accompany it. By the 
aid of the thermometer, however, we may seek for its manifestations in the 
central regions of the organism. 

Gentlemen, it is especially in diseases where the temperature rises 
above the normal standard, that the importance of clinical thermometry 
can be readily made manifest ; but there is a certain class of diseases, 
especially in old age, which give rise to reverse phenomena, by inducing 
actual lowering of the temperature. Now, this central algidity assur- 
edly cannot be recognized except by the aid of the thermometer, which, 
under such circumstances, may be called upon to render the greatest service. 
This is a subject which is still almost uninvestigated, so to speak,but which, 
nevertheless, I hope will furnish us with an opportunity to learn some im- 
portant facts. 

I. — Before entering into the consideration of the subject, let us estab- 
lish a few preliminary facts. 

A. — Normal temperature in old age. — You know that in old age the res- 
piratory function is decreased, as shown by a diminution in the amount of 
carbonic acid exhaled, by an increase in the number of inspirations, and by 
an appreciable reduction in the vital capacity of the lungs. It is likewise 
admitted that the nutritive movement of composition and decomposition 
is similarly lowered at this period of life, although I do not know that any 
decisive investigations have ever been undertaken concerning this latter 
point. However this may be, gentlemen, it is a remarkable fact that, in 
spite of these evidently unfavorable circurn stances, the temperature suffers 
no appreciable modification from theprogress of years : 37.2°, 37.5° (99° Fahr., 
99.5° Fahr.), and rarely 38° (100.5° Fahr.) in the rectum, and now a little 
less or a little more than one degree (a degree and one-half Fahr. ) above 
this point in the axilla. This is the normal temperature in old age, even 
to the extreme verge of life, according to the very numerous investigations 
I have made on the subject. 

De Haen, in former years, and Von Barensprung more recently state 
that the temperature in very old people is lower than these figures. I do 
not believe it to be the case except in unusual instances ; three years ago, 
in one of these meetings, I introduced a woman who was over one hundred 
years old and who was in excellent health ; her axillarv temperature was 
habitually 37.4° (99.3° Fahr.), and the rectal 38° (100l5° Fahr.). Since 
then I have seldom found this temperature of 38° (100.5° Fahr.), represent- 
ing that of the normal state, even in individuals who have attained the ut- 
most limits of the senile period of life. 

To give a resume, then, the central temperature is the same in the aged 
as in adults ; I may add that in both cases it presents the same un- 
alterability, and that it is only raised in a slightly appreciable, but tempo- 
rary manner in pathological conditions. 



1G8 CLINICAL LECTURES OX 

How may we explain the fact that the normal temperature in old age is 
found to be at least as high as in adult life, when in the senile state the 
nutritive functions are so perceptibly diminished ? TVe must here un- 
doubtedly adduce the condition of the skin in particular, for in old people 
it presents a marked impoverishment in its network of capillary blood- 
vessels, and at the same time its secretory activity is much below that of 
adult life. Probably less heat is generated in old age than in adult life, 
but old people do not lose so much either by the skin or by the pulmonary 
apparatus ; and thus is established a compensation. 

B. — Axillary and rectal thermometry in old age. — I cannot leave the subject 
under consideration without offering a few remarks concerning thennom- 
etry in old age, when practised in the axilla, compared with thermometry 
of the natural cavities, particularly the rectum. You will often hear allu- 
sions made to rectal temperature, and, indeed, the rectum is the natural 
cavity, which is always preferably taken as the locality for thermomi 
explorations in aged individuals. I must acquaint you with the reasons 
which, from the beginning of my studies of this subject — thai 
during a period of nearly seven years — have determined me in a choice 
that at first view might appear strange. 

Gentlemen, it is easily proved and readily recognized that the temper- 
ature taken in the axilla is always lower than that exhibited after a 
exploration ; the arm-pit, from the standpoint of temperatun 
mates to the surface of the body ; the rectum represents the internal vis- 
cera. In truth, the difference between the temperature of these two local- 
ities in the adult, besides being usually very slight, is never 
always a (fixed) proportional difference. But this is not so in old age, 
where the figures representing the difference are sometimes com 
over a degree, for example (a degree and a ita/f Fahr.), and again much 
according to the most varied circumstances. Thus, in old age the © 
temperature alone is permanent, while the axillary temperature, on the 
contrary, presents extreme fluctuations, like those of the integume: 
though to a less extent. 

But it is in the pathological, and above all in the febrile state, that we 
see revealed in all its completeness the relative variation 
tral and the external temperature in the senile period of life. I show you 
a chart pertaining to a case of lobar pneumonia occurring in a woman fifty- 
five years of age ; you see that the curve of the rectal temperature and that 
from the axilla, although nearly parallel in a general way, yet diverge from 
each other in a most irregular manner at different portions of th< 
At several places you can even see these two curves pit aenti tions 

in opposite directions. Thus, on the fifth day of the disease, in the I 
ing, at the very time the axillary temperature stood at only 
Fahr.), that of the rectum marked 40.2 (10-4.-4 Fahr.), : more 

than three degrees (nearly six degrees Fwhr A That evening the : 
approached, the difference not being over a degree {a degree and a half Fahr.). 
On the sixth day the two curves almost touched at one time, but ti- 
after they again notably diverged. This patient had had I Uablo 

diarrhoea, and at several distinct times there were sympt< 
denced by well-marked coldness of the cutaneous surfaci 
recur to the signification possessed by these indications of collapse, which is 
a state quite often observed during the course oi acute 
pie ; let it suffice for the time being to insist upon this point, namely, that 
the striking disagreement we have shown to exist in th< 



THE DISEASES OE OLD AGE. 1G9 

case (taken as an example) between the data furnished by the axillary and 
rectal curves of temperature, is very frequently met with at the clinic of 
the aged. 1 

This is the principal reason that induces me to prefer the practice of 
rectal rather than of axillary thermometry ; there is another — very subordi- 
nate, however — which, while it would not have been sufficient to determine 
us in our choice, is nevertheless not devoid of all value. At least fifteen 
minutes are necessary, in the aged, to obtain an exact reading from an ax- 
illary exploration. At the end of five minutes, on the contrary, the mercu- 
rial column of the instrument ceases, as a rule, to oscillate when inserted 
into the rectum. In view, therefore, of its facility of accomplishment, you 
see that rectal thermometry possesses a marked advantage over the other 
method, and an advantage not to be slighted in the practice of a large hos- 
pital. 

I need say nothing concerning the very natural reluctance which the 
patients frequently manifest to the application of this form of examina- 
tion, since persuasion almost always removes the difficulties arising from 
this objection. 

C. — Bodily temperature in the pathological state in the aged. 

First. — Extreme limits of the central temperature above and below the nor- 
mal standard. 

Gentlemen, there is a certain number of fundamental facts in clinical 
thermometry, which have been verified very many times, and which may 
almost be advanced as axioms. Permit me to state to you some of these 
all-important facts. 

Whenever the central temperature, whatever the period of a disease, and 
whatever the character of that disease maybe, rises to 41.5° (106.7° Fahr.), 
there is imminent danger. If it reach 41.75° or 42° (107.2° or 107.6° 
Fahr.), death is certain. These figures, which Wunderlich gives concern- 
ing adult pathology especially (loc. cit.), I affirm to hold good in all their 
signification in the aged ; indeed, we may say that in old people 41° Centi- 
grade (105.8° Fahr.), already marks a most critical situation. 

If the elevation of the central temperature above a certain point indi- 
cates per se, and independent of the concomitant circumstances, the great- 
est danger, so also a fall below the normal standard when it reaches a cer- 
tain point — 35° for example (95° Fahr.) — reveals a most serious condition, 
only, however, in my judgment, so far as it affects cases of old age. 

Thus, gentlemen, you notice that there are almost fixed limits beyond 
which, it seems, the temperature cannot pass without seriously compromis- 
ing the life of the patient. Temperatures that go beyond these limits very 
rarely occur ; they are the exception, and the forerunners, of a certain, fatal 
termination. 

You cannot have escaped observing that clinical thermometry has 
already furnished us, for prognosis at least, information of the highest im- 
portance, since its signification is, so to sjoeak, absolute. We shall frequently 
have an opportunity to demonstrate other equally noteworthy applications 
of it. 

Second. — Low, medium, and high febrile tempjeratures in the aged. 

In general terms it may be stated that a temperature rising a little over 
38° (100.4° Fahr.), corresponds to a mild fever (subfebrile temperature) in 

1 A reproduction of the chart employed in the elucidation of the preceding para- 
graph is not given in Professor Charcot's book. — L. H. H. 



170 CLINICAL LECTURES OX 

the aged as well as in adults ; under 39.5° (103.1° Fahr.) it is of moderate 
intensity; between 39.5° and 40° (103.1° and 104° Fahr.) it is intense; 
and above 40° (104° Fahr.) it is exceedingly intense (liyperpyretic tempera- 
ture). 

These data, like the preceding, are as applicable in the case of the aged 
as in that of adults ; for, with regard to the degrees of temperature that 
may be reached in the febrile state, the former are in no way inferior to the 
latter. This is a point that formerly I endeavored to establish, and which 
my subsequent investigations have but confirmed. 

But, gentlemen — and here is an important fact for your consideration — 
in the comparison I have instituted between adults and the aged, from a 
standpoint of febrile temperature, I have spoken only of healthy individuals 
— that is to say, only of those free from all previous disease, from all ca- 
chexia, at the time the fever developed ; for it is certain that in subjects 
already enfeebled, whatever may be their age, the temperature (even when 
the disease is of a nature habitually inducing intense febrile movement) 
cannot rise during the whole course of the raaJady above the medium fe- 
brile temperatures 39° to 39.5° (102.2 to 103.1° Fahr), though Che case be 
most serious and must terminate in death. But, I repeat, and it is impor- 
tant to remember it — in my opinion, this deficiency with regard to thermal re- 
action is not a characteristic of the senile period of life. 

In a woman seventy-five years of age, feeble and cachectic, who was at- 
tacked with lobar pneumonia, the maximum temperature at the height of 
the disease only once exceeded 39.6° (103.1° Fahr.). In another c 
pneumonia, occurring in a woman about fifty years old— and consequently 
relatively young — but who had carcinoma of the uterus in an advanced 
sta^e, and a well-marked cachexia, the maximum temperature never reached 
40° (104° Fahr.), but remained at 39.5 (103.1 Fahr.) or below. This 
patient, like the preceding, died in the defervescence, which is the most fre- 
quent mode of termination in cases of this kind. You recognize how anal- 
ogous, in all respects, are these two observations, although taken from sub- 
jects so very different in years. 

And now let us look upon the reverse of this demonstration : the three 
curves that I now show you ' are tracings from three different individuals — 
one a child three years of age (Ziemssen) ; the second a man thirty-eight 
old (Wunderlich); and the third a woman of seventy-five, taken in thie 
pital. Each is a case of lobar (croupous) pneumonia. You observe that 
striking resemblances approximate them, and. were you not duly informed, 
you would with great difficulty be able to distinguish one from another. 8 
when AYunderlich {fee. eit.) affirms that, from mere inspection of a far 
of a thermometric curve, the age of the patient becomes known, since in 
old age the maximum is relatively at a lower point, his proposition do. s 
not seem to me to be perfectly exact. Bather, say we can lveognize whether 
it comes from a robust individual, or, on the other hand, from one pre- 
viously enfeebled. 

Third. — The danger, in the aged, of high temperature contin 
days. 

A third point now demands attention : a hyperpyretie temperature, 
40.5° (104.9 1 " Fahr.), may occur and yet the case not be serious, provided 
it remain at this point but for a very short period of time. as. for example, 
in a paroxysm of intermittent fever, or in abortive pneumonia. But if 

1 A foot-note in the original savs : " W* do n<t think it n<wss<iry to insert th* thrtt 

tracings in the tej.'t.''—L. H. H. 



THE DISEASES OF OLD AGE. 171 

such a temperature persist for several days almost without interruption, as 
occurs in diseases of a continued type — lobar pneumonia, for example — the 
case is very grave. What I state is based upon numerous observations 
that I have made concerning this subject, with reference to the pneumonia 
of the aged ; but it seems to be established that it is nearly the same at 
other periods of life. However that may be, in the majority of cases of 
lobar pneumonia observed in the Salpetriere, death has supervened when, 
during the height of the malady, the maximum temperature has several 
times exceeded 40.5° (104.9° Fahr.) ; when, on the contrary, the highest 
temperature has been 40° (104° Fahr.), or under, recovery was of frequent 
occurrence. 

Let us not conclude from this, however, that all cases of pneumonia in 
the aged where the temperature is relatively low are mild, benignant. 
Far from it ; you know already that many — nay, perhaps the majority — of 
cases of low temperature pneumonia, so-called, are remarkable on account 
of their fatality. But this is a point to which we shall recur many times 
in the course of the following lectures. 

II. — You have seen the very practical importance of the facts that have 
just been adduced, but we know them only as the result of a purely em- 
pirical study, made without any theoretical prejudice whatever. The in- 
terest with which you have been inspired would certainly have been very 
much increased if we had attempted to penetrate into their physiological 
reason. Whence, indeed, these narrow limits traced upon the thermome- 
tric scale, that cannot be reached without seriously endangering life, and 
beyond which there is no longer any hope of saving the patient ? "Why 
does the temperature, rising to a point much short of these limits, yet per- 
sistently for several days without appreciable remission, announce a serious 
condition, whatever the disease it may accompany ? 

Such are the questions you have put yourselves. We cannot, in the 
present state of science, give them a definite, a rigorous solution ; but we 
may at least hope, relying upon the data furnished by pathological physi- 
ology and experimental pathology, to discover in what direction the solu- 
tion is to be found. 

Let us agree, in the first place, that the derangement of the whole 
economy, called fever, constitutes, per se, a real danger when it is intense, 
independent of the cause that produces it. An individual is attacked with 
pneumonia ; the respiratory functions are no more deranged than is cus- 
tomary in such cases ; there are no complications, yet the patient dies in 
the midst of an intense febrile movement. The autopsy is made, and re- 
veals lobar hepatization, which auscultation had recognized during life, 'but 
which is limited to such a small extent of a lobe of the lung that it is im- 
possible to admit that the local lesion accounts, in this case, for the fatal 
issue. It is sufficient to offer this one example, for — thanks to the prog- 
ress of pathological anatomy — we no longer believe, with Hoffmann, that 
the autopsy always discovers some great lesion in one of the organs that 
explains the cause of death. The constitutional condition, then, must be 
charged with the burden, and the febrile state in particular ; but, in the 
midst of this almost general derangement of the organism, where is the 
element that is, above all others, to blame ? 

Here we are forced to digress. 

The febrile state, with its train of symptoms — some fundamental and 
essential, others accessory : the rise in temperature, the acceleration of 
pulse, nervous derangements, and the rest — the febrile state is the result 



172 CLIIHCAL LECTURES ON 

of most complex phenomena, which may, nevertheless, be reduced to a 
small number of prime elements. 

The starting-point seems to be a rapid metamorphosis, or, rather, an 
untoward combustion of the blood and tissues, which occurs almost every- 
where in the organism, and is excited by the action of a morbific poison, 
or any other cause. 

The rise in the central temperature is one of the appreciable results of 
the intimate chemical action constituting this exaggerated combustion. 

The products of this combustion — organic waste, urea, and 
accumulate in the blood, and circulate along with it. Necessarily, they 
should be thrown out, sooner or later, by the natural emunctoiies, since 
there is no place for them in the organism. 

Besides, in a case of fever with local disease, certain derangements, re- 
sulting from the abnormal functional action of the diseased organ, are super- 
imposed upon the general disorder produced by fever. Thus, in double 
pneumonia and capillary bronchitis, lipomatosis is seriously impeded, and 
anoxcemia — an accumulation of carbonic acid in the blood — may occur. 
Or, when acute parenchymatous hepatitis (acute yellow atrophy of the 
liver) occurs, the materials destined to form bile are retained in the blood, 
on account of the rapid destruction of the secretory elements of the organ, 
and the result is acholia. 

But I do not mean to enter into details, and so shall keep to the most 
general facts. 

Whence, then, comes the danger in fever? 

The rapid consumption of tissue, exhibited by more or less marked 
emaciation, diminution of the body-weight, and prostration of the forces, 
cannot be adduced, at least as the chief i 

that develop slowly. It cannot play a principal part in a fever thai Lb 
idly evolved, such as the fever induced by lobar pneumonia, which we just 
now gave as an example. 

The presence in the economy of organic dibris or waste, the product 
of febrile metamorphosis, also undoubtedly constitutes a serious danger, 
in cases where excretion of these products is imperfectly performed. In- 
deed, we here find the conditions for an auto4< products, 
in certain proportions, are for the most part deleterious. This auto-tox- 
aemia cannot occur as cholsemia and anoxaemia * — of which we shall - 
speak — except in certain peculiar circumstances, which we shall allude to 
farther on in the course of these lectures. Besides, it is revealed bj 
cial symptoms which do not belong even to the most intense febrile si 

There remains, then, the rise in temperature. 

Can it be that organs and tissues, when submitted for a certain period 
of time to the extreme temperatures we have just enumerated. ond< 
sufficiently profound change in their material condition to rend, 
capable, at a given moment, of performing their proper functions ! With 
this as an hypothesis, the elevation of temperature in fever is not only 
suit — a symptom, but is indeed the cause of derangements tonally 

serious enough to induce death. 

The common people, who scarcely know anything concerning fever, ex- 
cept the fever-heat, readily admit "that intense fever may kill tJ 
This popular belief, gentlemen, should not be treated with I h dis- 

dain ; for it has received recognition, to a certain ix: 

1 Auto, self; CeotanmW, blood-poisoning. — L. IT. H. 

■An, privative; OZM6, oxygen; tamo, blood. — L. H. II. 



o 



THE DISEASES OF OLD AGE. 173 

teachers in our art as Sydenham, Boerhaave, and Van Swieten. Becently 
it has been taken up again and, so to speak, resuscitated by many authors 
of good repute, among them Liebermeister * of Germany, and Eichardson 
of England ; and the arguments these physicians advance in its favor ap- 
pear deserving of serious consideration. 2 

The best arguments have been furnished by experimentation. The cen- 
tral temperature can, you know, be artificially elevated in man as well as in 
the lower animals, and a condition closely resembling the febrile state may 
be thereby produced. The disorders which result when the bodily tem- 
perature is thus elevated to a certain point above the normal standard re- 
call the symptoms of fever : thus, the pulse is accelerated and the respira- 
tory movements are quickened ; an inexpressible sense of malaise supervenes, 
and we have cephalalgia, various nervous derangements, slight disturbance 
at first, and extreme prostration of the forces afterward ; and when, in the 
case of animals, the experiment is pushed farther, coma, general resolution, 
and finally death, supervene. 

Indeed, it is known from the celebrated experiments of Blagden and 
Dobson, that a man may be submitted to very high temperatures, even for 
quite a long time, without the occurrence of any very noticeable derange- 
ment ; thus, Eichardson recently bore a temperature of 212° Fahr. (100° 
Centigrade) in a hot-air bath for nearly twenty minutes, without any discom- 
fort. 3 But this is possible only under the express condition that, durin 
the experiment, the central temperature si tall not rise above a certain point. 
In such cases, as you know, the pulmonary and cutaneous surfaces are the 
seat of enormous discharges of heat, thus establishing a compensation : be- 
sides, these experiments are only possible in dry air. But, in a hot-water 
bath with a temperature of 40° to 44° C. (104° to 111.2° Fahr.), or a tem- 
perature no higher than 40° or 45° C. (104° to 113° Fahr.), there is great 
peril, inasmuch as the temperature rises — such a case is recorded by Bar- 
tels-to 39°, 40°, and even 41° C. (102.2°, 104°, and 105.8° Fahr.). In 
Bartels' case, and almost immediately, such grave symptoms were produced 
that dissolution seemed imminent. 

Under conditions strikingly similar to these, that terrible accident — sun- 
stroke — so well known to the English physicians in India, is produced ; as, 
likewise, that analogous state popularly expressed as being overcome by the 
heat. This is fatally exemplified, in climates like ours, when armies are on 
the march during sultry, hot weather ; the unfortunates who are thus sun- 
struck are at times almost literally overwhelmed — blasted, cases of this kind 
being recorded where the central temperature rose at the time of death to 
44° (111.2° Fahr.) 

But, returning to experimentation, let us consider those cases— of course 
we speak only of animals — where it has been carried to the utmost limit. 
Now, gentlemen, death always ensues, and in an almost wholly unexpected 
manner, when the central temperature exceeds by 4° or 5° (7.2° or 9° Fahr.) 
the normal standard of the animal under experiment, say 45° (113° Fahr.) for 
mammals. There is, as you perceive, a fatidical point for every species of 
animal, which cannot be attained without a fatal termination. 

1 Ueber die Wirkungen der Febrilen Temperatursteigerung : Deutscbes Archiv. 
Bd. i. 18G6. Niemeyer Speciel Patholog. 7 Auflag. 1868. 

8 Medical Times. May, 1869. 

3 Drs. Fordyce and Blagden were able to remain with impunity in a chamber heated 
to 260° Fahr. (127" Cent.), and with comparative ease in one so hot that it became pain- 
ful for them to touch the metal buttons of their clothing. (See Phil. Trans. 1775, 
pp. Ill, 484.)— L. H. H. 



174 CLINICAL LECTURES ON 

This recalls what we have lately remarked concerning man in the path- 
ological condition. You have not forgotten that death is certain — is a ne- 
cessary sequence, indeed — when a temperature of 42° (107.6 C Fahr.) is 
reached in the adult — that is to say, when the normal standard is exceeded 
by about 5° (9° Fahr.), — and a little lower than this in the senile period ; 
and hence it is at least very likely, that in the latter instance, as in the case 
of animals experimented upon, the fatal issue must be largely attributed 
to the extreme elevation of the central temperature. 

But what is the mechanism of death ? The experiments of Claude Ber- 
nard, 1 and Calliburces, repeated by Panum, establish the fact that it is the 
heart which especially suffers in these cases ; at first excited in its functional 
activity, it finally ceases to beat when the temperature reaches 45 (113 3 
Fahr.). The organ presents no gross lesions, but its tissue has undergone 
profound changes, muscular rigidity being produced comparable to cadav- 
eric rigidity, and movements cannot possibly be induced, even for a time, 
by subjecting it to the influence of excitants. 

A marked alteration in the constitution of the blood likewise occurs : 
sometimes it is very fluid ; sometimes, on the other hand, coagulated. Ac- 
cording to Richardson, the first occurs in cases of very sudden death ; the 
second when death has been postponed for some time after the commence- 
ment of the experiment. 

In this connection, let us not forget that, in pathological conditions oc- 
curring in man, where death has rapidly ensued, and has been pi 
a considerable rise in temperature, the blood has somet.: o found in 

a state of extreme fluidity, and sometimes, on the contrary, coagulated 
withiu the cavities of the heart. Boerhaave thinks that coagulation of the 
blood in the vessels is one of the causes of death in fever, and quite recently 
Weikart has endeavored to prove that this, indeed, was the attributable 
cause in cases where the temperature rose to about 42 ; (107.G : Fahr. ). 

All the preceding facts have reference to cases wherein death followed 
extreme elevation of the central temperature. In those in which the f< 
heat was maintained for a longer or shorter period at a lower, although still 
relatively high point, we can no longer appeal to the data furnished 1 
perimental physiology, for experiments have never been made in tlii- 
ticular direction. But we may, nevertheless, adduce certain facts that tend 
toward making us admit that even here elevation of temperature m 
se induce serious symptoms, and itself be the actual danger. 

Let me first observe, with Liebermeister. that most febrile affections, 
whatever may be their nature, in which the temperature is maintained at a 
high point during a certain time, and in a more or less permanent ma 
possess an almost constant and common character. In such 
certain organs present, at the autopsy, parenchymatous changes that have 
sometimes been designated by the name of steatosis. The liver, the mus- 
cles of organic life, the kidneys, and the heart especially, undergo ti. 
generation. I shall only cite, in this connection, the more or less marked 
softening which the last-named organ may undergo in typhoid fever — ac- 
cording to Louis, and in typhus— according t 
always accompanied, during life, by symptoms of cardiac weakr. 
tolism. Can we ascribe these changes, especially those of the heart and the 
consequent derangements, to the permanence' of the high temperature? 
"W e might be led to admit it from the action that extreme 
exert on the cardiac tissue. 

1 See the recent investigations of Claude Bernard on the inliuenee of heat upon ani- 
mals : Revue Scientifique. Nineteenth year. Xo. S. 1871. 



THE DISEASES OF OLD AGE. 175 

It is well known, too, that great acceleration of the pulse, which is one 
of the most dangerous symptoms in cases of this kind, is, to a certain ex- 
tent proportional to the rise in temperature. 

But here is an argument that bears rather more directly upon the ques- 
tion ; it is derived from the undoubted advantages of antipyretic treat- 
ment adopted in the case of acute diseases accompanied with high tempera- 
ture. Now, what is at the same time the most prominent, the most constant, 
and the best-established result of the various remedies employed in this 
method ? It is a more or less well-marked lowering of the central tempera- 
ture, for a longer or shorter period of time, even at the acme of an intense 
febrile movement. Thus do digitalis and veratrum act in pneumonia, and 
sulphate of quinine in acute articular rheumatism ; in this way, too, act the 
prolonged and frequently repeated cold baths, recently employed with so 
much enthusiasm by the Germans in their treatment of typhoid fever, and 
which seem to have produced results that are certainly worthy of attention 
(Brand, Jurgensen, Liebermeister, and Gerhardt). 

From the preceding, we think we can offer this conclusion — not, indeed, 
as the result of a rigorous demonstration of its truth, but at least as a very 
probable hypothesis, namely : a rise in the central temperature, in fever, itself 
constitutes a danger. 

Let us leave for a moment the discussion of fever and rise of tempera- 
ture, to consider a thermometric change in the other direction ; let us see, 
in other words, why a fall of temperature to a certain point below the nor- 
mal standard is almost necessarily followed by death. Has the cold devel- 
oped in such cases within the organism a positive action upon organs and 
tissues capable of diminishing the degree of energy of organic activity ne- 
cessary to life ? Gentlemen, there can be no doubt but that such is actu- 
ally the case. 

When an animal is, under certain circumstances, submitted to the action 
of a low temperature, in a state of complete inanition, poisoned by cer- 
tain substances — opium, ammonia, hydrocyanic acid — his body covered 
with an impermeable jacket, as in the experiments of Fourcault and Eden- 
huisen, the central temperature always falls, and at the same time the res- 
piratory movements become feebler and feebler ; the absorption of oxygen 
and the exhalation of carbonic acid are diminished. 1 If the experiment is 
carried farther, the temperature falls to a point below which death will 
ensue. Now, what occurs in these various circumstances ? It may be said 
the animal dies of cold. He dies of cold, since artificial heat always retards 
the fatal termination — indeed, even permitting, in the most favorable con- 
ditions, a complete restoration to life. 2 

Thus, gentlemen, theoretically as well as experimentally, heat and cold, 
when carried to a certain extreme in the organism, are elements of prime 
importance, and elements that must be taken into account, not only to 
establish a prognosis in a given pathological condition, but also to regulate 
the administration of therapeutic agents. 

But I perceive — a little late, perhaps — that the digression I entered into 
has led me far astray, and that it is time to return to senile pathology. 

It is not enough to have recognized that, in old age, the elevation or 
fall of the central temperature to a certain point has the same significance 
as at the other periods of life ; we must actually establish the fact that os- 
cillations of temperature carefully recorded day after day, hour after hour, 

1 Valentin : Arch, fiir phvsiol. Heilk. , p. 433. 1858. 

2 Brown-Sequard : Soc. deBiologia. Vol. i., p. 102. 1849. 



176 CLINICAL LECTCEES ON 

in the form of graphic tracings, furnish constant and characteristic types 
for ever} 7 disease in the aged as well as in adults, as I have already demon- 
strated in case of the latter. For it is upon this very circumstance that a 
diagnosis of febrile diseases by means of temperature is founded, a method 
that has received much attention at the present day. You will see, as I 
have already indicated, that these specific types do not undergo noteworthy 
change, notwithstanding the age of the patient ; in their essential features 
they are in the aged what they were in the adult. In our next lecture we 
shall endeavor to bring additional proof in support of this assertion ; we 
shall then have an opportunity to review, frora this particular point of view, 
the diseases which produce fever in the aged. 



THE DISEASES OF OLD AGE. 177 



LECTURE XX. 

Summary. — Thermal Characteristics of Febrile Diseases in Old Age — Febrile Diseases 
of the Continued Type — Febrile Diseases of the Remittent Type — Febrile Dis- 
eases of the Intermittent Type. 

Rapid Rise in Central Temperature, at the Time of Death, in Certain Diseases 
of the Nervous Centres — Tetanus — Epilepsy — Hysteria — Cerebral Hemorrhage and 
Softening — Epileptiform and Apoplectiform Attacks. 

Gentlemen : — At the close of my last lecture I told you that the funda- 
mental characteristics of thermometric curves are not strikingly altered in 
old age. Let me justify this assertion by taking for examples some of 
those febrile diseases, called typical, that occur in old people. These dis- 
eases may be arranged in three groups, according as the febrile type is 
continued, remittent, or intermittent. 

A. — Thermic Characters of those Febrile Diseases op Old Age Denom- 
inated Typical. 

First. — Febrile diseases of the continued type. — These are much less nu- 
merous than in the adult ; the eruptive fevers do not occur. Nevertheless, 
I have occasionally seen small-pox in the Salpetriere. In the majority of 
these cases it assumed the hemorrhagic form attended with collapse. The 
patients usually suffered a remarkable lowering of the central temperature, 
a true algidity, a condition quite worthy of your attention, and of which I 
purpose to speak in the next lecture. 

The principal disease of this group is lobar (croupous) pneumonia, which, 
notwithstanding the contrary statement of many authors, is more frequently 
observed in old age than broncho- (catarrhal) pneumonia. 

a. — The disease is usually ushered in by a chill — the statement that the 
aged seldom have a chill is wrong. At the same time the extremities be- 
come cold. This period, the pyrogenetic, is marked by an abrupt rise in the 
thermic line. The next day the temperature rises to 40° (104° Fahr.), for 
example. This characteristic is of itself amply sufficient to distinguish 
this disease from those of the following (second) group, where the rise is 
slow and progressive. 

b. — At the time when the disease is at its height, the temperature, hav- 
ing attained a certain point, remains nearly stationary for a number of 
days. We must, nevertheless, note the occurrence of diurnal variations, 
quite narrowly limited and not exceeding a degree (a degree and a half 
Fahr.). In its development this part of the curve exhibits, at times, a pro- 
gressive tendency to rise, and then we have to deal with a serious case ; 
again, there is a tendency toward a fall in temperature, occasionally pre- 
dicting a favorable termination, but only when the other symptoms, taken 
collectively, are not aggravated. 

The regularity of the curve may be altered through various circum- 
stances ; it is enough, for the present, to mention the modifications re- 
sulting from the administration of drugs. 
12 



178 CLINICAL LECTURES ON 

c. — The third period is marked by a different curve, according as the 
termination is to be fortunate or fatal. 

In the former case you observe a period of healthy defervescence,, occa- 
sionally preceded by a temporary exacerbation of all the symptoms at- 
tended by an abrupt ascent of the curve. This corresponds to what the 
ancients called the j)erturbatio critica. This aggravation of symptoms is of 
short duration in cases that are to recover, lasting only a few hours. Def- 
ervescence then occurs, and usually runs a very rapid course ; the curve 
descends with a single stroke, thus recalling inversely the rapid variations 
in temperature that marked the commencement of the disease. In this sud- 
den fall we often observe the occurrence of subnormal temperatures, attended 
by symptoms of collapse, which we shall consider later on. Soon, how- 
ever, the curve regains the normal level, and stays so permanently. Con- 
valescence has begun, in spite of the persistence of local symptoms. 

It is generally after the beginning of defervescence that we notice those 
critical phenomena which so attracted the attention of the ancients. Here 
thermometry shows itself superior to the older method of observation, 
since the final lowering of the temperature precedes the appearance of the 
critical phenomena. In passing, let me remark that, in old age, these oc- 
currences are less frequent than in adult life. In very rare instances they 
consist of epistaxis or sweats, but generally they are exhibited either by 
diarrhoea, or again, by copious passages of turbid urine. 

When there is to be a fatal termination we sometimes notice a rapid 
rise in the temperature, which we have occasionally seen to continue in- 
creasing even after death. This is in the vast majority of cases what gen- 
erally occurs in the adult And it is also what we observe in healthy old 
people ; whereas, in enfeebled aged individuals, death commonly occurs in 
the defervescence. In this ominous defervescence the temperature does 
not generally fall as low as in favorable defervescence. In our next lecture 
we shall see by what characteristics we can affirm whether the termination 
is to be in death or recovery, in cases where defervese<. in at the 

decline of lobar pneumonia. 

Second. — Febrile disease* of the remittent type. — Here lobular or catar- 
rhal pneumonia assumes the first rank ; and indeed, i we already 
said, it is much rarer in old age than has been supposed. 

In the pyrogenetic period the ascent is slow and jerking. In the acme 
the daily oscillations are quite extensive, usually greater than a de<_rree (a 
degree and a half Fo.hr.); lastly, there are no critical phenomena at the mo- 
ment of defervescence. 

Concerning typhoid fever and acute catarrhal phthisis, the most promi- 
nent and important diseases of this group in adult life, we may say that 
they are almost wholly wanting in old age. 

Third. — Febrile diseases of the intermittent type. — In the Salpetrifcre, palu- 
dal fever is very rare ; indeed, I am not absolutely positive oi ever having 
seen it in this hospital. Symptomatic intermittent level's, from diseai 
the urinary or biliary passages, are, oil the contrary, tery frequently met 
with in this institution. These symptomatic fevers can be distingu 
from paludal (malarial) intermittent fevers (ague) by nu tain char- 

acteristics, and from their frequence they seem to deserve so much 
tion that I shall devote some of our future meetings to their consideration. 1 

1 The recent thesis of Dr. Maurnin contains the ml - 
quelques Accidents de la Lithiase biliaire. Paris. 18 - I Appeudix. 

{There is no "Second Appendix' 1 to the book.—L. II. EL . 



THE DISEASES OF OLD AGE. 179 



B. — The Eapid and Considerable Kise of Central Temperature Occurred 
at the Time of Fatal Termination in Some Diseases of the Nerve- 
Centres. 

Until this moment we have only been concerned with febrile diseases ; 
but in the course of other diseases we may, at a given moment, witness an 
abrupt and very great rise in the central temperature. Let me dwell a few 
moments upon the study of this phenomenon, that is yet hardly known, al- 
though meriting attention, were it only on account of its prognostic im- 
portance. 

Deep coma, sometimes, though rarely, preceded by delirium, a very 
great increase in the pulse-rate, contracted pupils, occasionally tonic or 
clonic convulsions, the rapid development of sloughing sores (eschars) about 
the anus — such are the phenomena that usually accompany the elevation in 
the central temperature under discussion. It occasionally reaches 41° or 
42° (105.8° or 107.6° Fahr.), or even higher ; and it may even go on in- 
creasing for a few moments after death. 

It may be asked, whether in cases of this kind we must rely on the or- 
dinary mechanism of fever to account for the production of these high 
temperatures. Wunderlich says, though rather vaguely, that "then the 
products of tissue-metamorphosis do not appear in excess in the urine." 
In two cases of tetanus observed in horses, Senator says that only a faint 
trace of urea was found in the urine. ' 

What may be said is that, in all these cases, the nervous system is pro- 
foundly involved. Diseases such as tetanus — traumatic or non-traumatic — 
and epilepsy of the variety called essential, are examples that furnish types of 
this terminal elevation of temperature. 

These two diseases are accompanied by tonic spasms, and it is gener- 
ally after repeated attacks that the fatal rise in temperature occurs ; but 
still we cannot adduce muscular contraction as the cause of this consider- 
able increase in heat, for in ordinary cases of tetanus or epilepsy the most 
intense convulsions produce but a comparatively slightly marked elevation 
in temperature (A. Monti: " Beitriige zur Thermometrie des Tetanus." Cen- 
tralblatt, No. 44, 1869). The thermometrie scale rarely marks 39° in 
these cases (102.2° Fahr.). On the other hand, in cases where this great 
terminal elevation has been observed, the convulsions have often long since 
ceased, and given way to a more or less profound coma. Some cases of 
hysteria, or at least of hysteriform affections, have been recorded, accompa- 
nied or not by convulsions, which terminated fatally, and presented this 
final elevation of temperature. 

One general fact is, that in no one of these cases, either in nerve-centres 
or in viscera, was there any recent material change capable of accounting 
for the terminal symptoms and rise in temperature. 

You know that in the general paralysis of the insane we quite frequently 
observe attacks that are at times apoplectiform and attended by more or 
less lasting paralysis, and again are of an epileptiform nature with subse- 
quent coma. 

The investigations of Westphal show that the temperature rises to 
about 39° (102.2° Fahr.) fifteen minutes or an hour after these attacks, 

1 Quite recently in a case of tetanus in a man, where the central temperature was 
elevated and death followed, Senator found the excretion of urea below the normal 
standard. — Virchow's Archiv. October, 1869. 



180 



CLINICAL LECTURES ON 



■whether convulsions have occurred or not. It falls rapidly if the case is a 
favorable one; but when death is to ensue, it continues high and even goes 
on rising. At the autopsy no other lesions are found save those of diffuse 
peri-encephalitis (meningitis). In some cases, however, the existence of 
sjDots of pulmonary induration has been determined, but by far the greater 
number of cases have no cause assignable for the terminal symptoms. 

I should not, gentlemen, have recalled these facts, which belong to the 
domain of pathology of mind diseases, were it not that they have their 
analogues in diseases more particularly belonging to senile pathology. 
"We have, in fact, in these wards a great number of patients who, for a 
longer or shorter period of time, have been attacked with hemiplegia fol- 
lowing upon cerebral hemorrhage or softening. Now, among these it is 
not uncommon to see the development of a disease marked by apoplecti- 
form or epileptiform attacks, recurring with more or less frequency. The 
greatest analogy, both as to form and consequence, exists between these 
attacks and the corresponding symptoms in the paralysis of the insane. 
Death may occur in, or subsequent to these attacks, as in diffuse peri-en- 



Days. 




1 






2 






1 






4 






5 






6 


































i » 






































107.6° F. 




























































/ 


































/ 1 


































f 








105.8° F. 


























\ 


























/\ 






« 




5? 


* 


3* 


























< 


0. 


< 
























O 




c 










/ 
















104° F. 














































































































































/ 


























102 2° F. 








/ 




































/ 
































/ 


































/ 


















- 


















/ 














































\ 



















Fig. K 



cephalitis, and in such cases we always observe a rapid and well-iuarked 
elevation of the central temperature. Now. however carefully the air 
maybe made, it is impossible to discover, either in the nen - M in 

the viscera, any recent lesion that is capable of explaining the gxa 

toms that resulted in dissolution. 



THE DISEASES OF OLD AGE. 



181 



107.6° P. 



105.8° F. 



"We only find old lesions (foci of hemorrhages or softenings) that ac- 
count for the hemiplegia, and secondary degenerations of the mesocephalon 
and brain-substance, the result of changes in the hemispheres. I think, by 
way of exemplification, that it may not be useless to exhibit two plates rela- 
tive to cases of this kind. 

The first is that of a woman, thirty-two years old, suffering incomplete 
right hemiplegia, dating from infancy, with the atrophy and contraction of 
the paralyzed limbs generally observed in such cases. 

After an attack much severer than usual, she was brought to the in- 
firmary. The rectal temperature was 38° (100.4° Fahr.) on the day she 
entered. The attacks became subintrant, occurring about one hundred 
times a day ; they were sep- 
arated by a coma which grew Days. 12 3 
deeper and deeper ; slough- 
ing sores rapidly formed on 
the buttocks and the patient 
died on the sixth day. The 
central temperature increased 
every day, reaching 42.4° 
(108.32° Fahr.) the day she 
died (Fig. 26). At the %)ost- 
mortem examination there 
were found, on the left side 
of the brain, quite a large de- 
pression, an extensive yellow 
patch, and atrophy of all the 
hemisphere on that side. 
There were no recent lesions 
of the nerve-centres or viscera. 

The second case is that of 
a woman, aged sixty-one, with 
right hemiplegia, the result 
of a cerebral hemorrhage of 
two years' standing. This pa- 
tient had already experienced 
several, though generally quite 
mild epileptiform attacks. One 
day an intense and prolonged 
epileptiform attack occurred, 
followed by a condition sim- 
ilar to that of apoplexy. Two 
hours after the beginning of 
this, the rectal temperature 
was 38.6° (101.48° Fahr.) ; 
five hours later it was 40° 
(104° Fahr.). Next day, not- 
withstanding the convulsions 

had ceased, the temperature was 41° (105.8° Fahr.) ; and the day after 
that— the day she died— it reached 42.4° (108.32° Fahr.). (See Fig. 27.) 

At the autopsy were found two ochreous foci — one in the corpus stri- 
atum, the other deep down in one of the convolutions. But there was no 
recent lesion that could be held accountable for the symptoms. 

A few moments ago, I demonstrated the clinical utility of thermometry 
in cases of this kind. I shall show you that the results it gives furnish 



104° P. 



102.2° F. 



















































































































/ 




















/ 




















/ 


















/ 












3 


a 


•JB 




/ 












<5 


a, 


< 




/ 












O 


<» 


<M 




/ 




































T 


















t 


















t 


















t 


















t 












































































































t 









No convulsions. 
Fia. 27. 



182 



CLINICAL LECTUKES ON 



most important indications not only for prognosis, but also for diagnosis. 
But I have not finished the enumeration of the diseases of the nerve-centres, 
in which ultimate high temperatures are met with. I shall now consider 
the diseases where there are recent lesions, and begin with those which are 
traumatic. 

Since the celebrated case of Brodie's, where the cervical marrow was 
crashed on account of luxation of the fifth and sixth vertebrae, and where 
the temperature was 43.7° (110.66° Fahr.), quite a large number of similar 
observations have been published (recently by Fischer, Xaunyn, and 
Quincke). In a lecture delivered in England several years since, Brown- 



Died. 



Days. 




1 






a 






8 






4 






b 
































f- 


... 




























































































1 






























J 






S 




* 




















/ 








ft. 




< 




















/ 








o 




o 




















I 






























I 
































/ 
































/ 
































f 








































100.4° F. 
















i 






















/ 






/ 




\ 




















/ 




\ 




























i 




\ 


/ 


















































98.6° F. 






























































i 





























Eschars. 



Fig. 38. 



Sequard had already collected records of some of thee and their 

analysis led him to the important conclusion that elevation of temperature 
presupposes a grave medullary lesion, whereas when the cord is merely ir- 
ritated we observe coldness. Dr. Fischer has quite lately drawn the same 
distinction. 

Moreover, this is not the case with lesions of the cord alone. Billroth 
has seen death rapidly ensue from a fissure of the cranium without 
external wound : the central temperature rose to 40.9° (105.6° Fahr.). 

AA e find these same characteristics in serious lesions of the brain. I 
traumatic in origin, such as hemorrhage or softening. I fa ed by 

repeated observation, that, in general, death in thee* - in the fcu 



THE DISEASES OF OLD AGE. 183 

is preceded by an abrupt rise in temperature, sometimes reaching 40° and 
41° (104° and 105.8° Fahr.). Thermometrical examinations here aid in es- 
tablishing our prognosis, for, as a general thing, the temperature does not 
exceed, or at least only by a very little, the normal standard in. case the 
apoplexy arises from cerebral hemorrhage or softening of recent date, when 
no phlegmasia complicates ; so that an abrupt rise in temperature, in such 
cases as these, is one of the most ominous signs. 1 I have, till the present 
time, met with only a very few exceptions to this rule. 

As I have said, there is a thermic characteristic by means of which 
apoplexy (with or without convulsions) arising from a recent lesion — hemor- 
rhage or softening — may be distinguished from those apoplectiform or 
epileptiform attacks occasionally supervening upon old cases of hemiple- 
gia. Indeed, in the latter case, the temperature is always more or less ele- 
vated during the first hours of the attack, 2 whereas in true apoplexy, caused 
by cerebral hemorrhage or softening of a recent date, there is at the begin- 
ning an almost constant lowering of the temperature below the normal 
standard (see Fig. 28). 

What is the physiological reason for the phenomena we have just de- 
scribed ? Wunderlich and Erb, the first who called attention to this subject, 
assume for the requirements of the case that certain parts of the nervous 
system possess, normally, a restraining influence (inhibitory action) upon 
the centres for calorification. Now, if these supposed moderating centres 
are profoundly injured, the result will be that the chemical acts productive 
of heat will be accomplished unrestrainedly — inordinately — and hence an 
abrupt and often enormous rise of temperature will be the consequence. 

But where is the seat of these restraining, inhibitory, regulating cen- 
tres? Recent experiments of Tscheschichin appear to give an answer to 
this question. 8 If the cord be cut transversely at different localities, the 
members become hotter as a result of the vaso-motor paralysis that follows 
such section ; but there is a simultaneous cooling of the central portions, 
arising partly from the discharge of heat, and partly from the cardiac weak- 
ness, the result of the peripheral accumulation of blood. But, if a section 
be very carefully made at the level of the junction of the protuberance (oc- 
cipital) and the medulla oblongata, the central temperature almost immedi- 
ately thereafter rises, to attain, at the end of two or three hours, a very 
high point. The pulse-rate and respirations are at the same time increased. 
From these results the experimenter has concluded that there are in the en- 
cephalon, above the point mentioned, moderating (inhibitory) centres whose 
paralysis induces an exaggerated and ungovernable production of heat. 

It would be desirous to have a repetition of these experiments. Should 
the results be confirmed, they could be usefully combined with clinical 
facts. 

1 Memoires de la Societe de Biologie. Vol. iv., Fourth series, p. 92. 1867. 

2 The comatose condition that terminates the majority of cases of cerebral tumor is 
likewise accompanied by a sudden elevation of the central temperature. I have seen 
this occur very frequently, and a case reported by Ladame also corroborates it. — 
Symptomatologie und Diagnostik der Hirngeschwiilste, p. 164. Wurzburg, 1865. 

3 Deutsch. Archiv, p. 398. 1866. 



184 CLINICAL LECTURES ON 



LECTURE XXI. 

Summary, — Central Algidity — The Disagreement that may Exist Between the External 
and the Deep Parts — Lowering of the Central Temperature in Chronic Diseases — 
Cancer, Ansemia, Diabetes, Phthisis — Lowering of the Temperature in Acute Dis- 
eases — Effects of Drugs and Poisons — Physiological Experiments — Septicaemia, 
Cholaamia, Uraemia — Cardiac Diseases — Pleurisy, Pneumothorax, Peritonitis — 
Diseases of the Spinal Cord — Clinical Significance of Collapse — Algid Pneumonia — 
Pestilential Diseases. 

Gentlemen : — Until the present moment we nave simply discussed some 
of the pathological states wherein the temperature rises above the normal 
standard ; but it is not rare, in old age especially, to observe the r* 
phenomenon during the course of certain diseases — that is to say, an actual 
diminution of the central temperature. To this subject I wish to-day to 
call your attention. 

While there are diseases wherein the febrile state constitutes an essen- 
tial, obligatory characteristic, there are none which / induce, in all 
their course, a lowering of the temperature below the normal standai 
that central algidity — for thus shall I designate the present subject — usually 
appears in the history of disease only as an episodic occurrence— a symp- 
tom that in the vast majority of cases is transitory. Let me add that fre- 
quently the gravest significance is betokened by this sign. 

Perhaps many of you, thinking of one of the most prominent symptoms 
of Asiatic cholera — the cadaveric coldness of the extremities — find that the 
proposition we have just enunciated is over-absolute. But thermometry 
does not stop with external phenomena. Now. what docs it teach us in 
Indian cholera? In the algid stage it is true that the temperature falls be- 
low the normal standard in a very remarkable manner — less, however, than 
the sensation experienced by the hand of the observer would lead him to 
suppose. The hands and feet, in the severest cases, give a themicmetric 
marking of 35°, 31°, 29° (95°, 87.8°, 84.2 Fahr.); but during this period, 
contrary to expectation — contrary to all the information furnished by axil- 
lary thermometry — the central temperature does not usually vary. This is 
a fact whose demonstration I commenced at the time of the epidemic of 
1866, ' and which, later, was confirmed, in a most striking manner, by in- 
vestigations, undertaken on a grand scale by GuterbOek of Germany, and 
niy colleague Lorain, of France. In seventy-four cases collected by the 
latter author, the rectal temperature fell to 35° (95° Fahr.) four tinu - 
only once to 34° (93.2° Fahr.) ; in five cases it reached 40 (104 1 
while in all the remaining cases it oscillated between 37* and 
and 100.4° Fahr.). Thus, in cholera itself, until now considered as the type 

1 Note snr la Temperature du Rectum dans le Cholera Asiatique : < 
des Seances et Memoires de la Societe de Biologie. Vol. xvii.. p. I 
1866. Lowering of the Temperature in D. Cherbaeh : TMa -bourg. 



THE DISEASES OF OLD AGE. 185 

of algid diseases, the coldness is all external, and does not involve the cen- 
tral portions of the organism. 

There is also quite a number of pathological conditions besides cholera, 
-where we notice a disagreement between the external temperature and that 
of the deep parts. In certain modes of death, for example, it is not un- 
usual to find the thermometric record from the rectum attaining hyper- 
pyretic limits, while the extremities remain cold. And, let me remark, the 
reverse never occurs. The increased heat of the external parts does not 
exceed that of the central temperature, except, perhaps, in the one case of 
local inflammations. John Simon concluded from his experiments that 
the inflamed region is a focus wherein the temperature may rise some 
tenths of a degree above that of the arterial blood which flows to the part. 
Kecent experiments of Weber have in fact confirmed this. 1 When the 
case is no longer one of inflammation, but rather of simple neuro-paralytic 
hyperemia, as occurs in certain forms of paresis, or in the course of cer- 
tain febrile diseases — pneumonia, 2 for instance — the temperature of the 
hypersemic parts is always lower than that of the deeper parts of the 
economy. 

I. — But, to return to central algidity. I have already said that it very 
rarely manifests itself in a persistent manner in the course of a disease. 
The few examples of this sort that we may cite concern chronic diseases. 
Cancerous affections should here be placed in the foremost rank, but only 
under certain conditions — when, for instance, we have emaciation, atrophy, 
and inanition going on to actual marasmus. Hence, it is in gastric and 
hepatic cancers that we especially notice this central algidity. With these 
exceptions, the temperature of the most varied forms remains about nor- 
mal, although there may be a slight increase in the central heat. This is 
a fact of which we became assured this year, from the observation of quite 
a large number of women afflicted with cancer either of the breast, uterus, 
or face. 

The same conditions of inanition and marasmus may be met with in 
other diseases than cancer ; in this connection we may mention profound 
anaemia, diabetes, and phthisis in certain cases. The temperature may 
remain lowered, often for quite a long period of time — at 36° (96.8° Fahr.) 
or under — which, however, does not prevent the temperature from under- 
going, at moments, and especially toward evening, a relative rise of one 
degree or more (one and eight-tenths or over, Fahr.), which is now and then 
evinced by a chill. Under such circumstances the body-weight progress- 
ively and rapidly diminishes, while the temperature continues to fall until 
dissolution occurs (Zehrfieber : O. Weber). 

It is undoubtedly on account of inanition that a more or less enduring 
fall in temperature has been quite frequently (Wolff) observed in subacute 
and chronic mania, with symptoms of depression, chiefly melancholia, at- 
tended with stupor. But the interpretation we offer cannot be applied to 
all cases of this kind. Quite recently, indeed, Dr. Lowenhardt, of Sachsen- 
berg, has reported two cases of insanity where the rectal temperature 
reached the almost incredible points of 31°, 32°, and 32.5° (87.8°, 89.6°, 
and 90.5° Fahr.), persisting during several weeks, while nutrition did not 

1 Recent observations of Jacobson and Bernhardt (Berlin Centralblatt, No. 19, 
1869), of Landieu (id), and Schneider {id., No. 34, 1870), seem to confirm the opinion 
of Hunter, and consequently invalidate the results obtained by Simon, Billroth, and 
O. Weber. 

2 R. Lepine : De THemiplegie Pneumonique. These de Paris. 1870. 



186 CLINICAL LECTURES ON 

appear to be affected in any noteworthy degree. One of these patients was 
excitable, the other erotic, and both took sufficient nourishment. ' 

IL — Central algidity is especially interesting, as an incident occurring in 
the course of acute diseases. 

First, however, let us seek for the principal conditions inducing, in such 
a case, this lowering of the temperature. 

A great number of substances employed as drugs have the effect of caus- 
ing a more or less profound depression of the central temperature. And 
it is especially when they are taken in large quantities, approximating to 
toxic doses, and principally, too, when exhibited in the course of the febrile 
state, that the action of these drugs is most energetically manifested In 
this way act digitalis, sulphate of quinine, calomel, and even alcohoL 

But when they are given under ordinary physiological conditions, they 
must be carried to relatively enormous doses before they produce a lower- 
ing of a few tenths of a degree. This, for example, is the case with al- 
cohol. 2 

"When these self-same substances are taken in toxic doses, they induce, 
in the majority of cases, a considerable lowering of the temperature, which 
perhaps contributes in great measure, as we have already remarked, to 
bring about a fatal result. Among other Babe at produce this re- 

sult we may mention chloroform, ether, alcohol, opium, belladonna, nicotine, 
phosphorus, and the majority of acids — sulphuric, oxalic, hydrocyanic, etc. 3 

It is interesting to note that, while a variety of drags and poisons have 
the power of lowering the central temperature, a very limited number of 
agents, on the other hand, possess the opposite potency. Y\ trcely 

mention more than three or four that have the property of increasing ani- 
mal heat. 

These are strong black coffee, tea (Lichtenfels and Frolich >. but to a less 
extent musk (Wunderlich), and finally, curare, which, according 
and Liouville, produces an actual febn in which the t mper- 

ature may rise to 40° (10-4' Fain.). 

This is the appropriate occasion for a study of the variations in tem- 
perature produced by the action on the organism of morbid poisons, and 
animal or vegetable substances in process of putrefaction. 

The majority of putrid matters introduced into the blood in pi 
logical experimentation have the effect of elevating the central temperature 
and causing an attack of fever, accompanied by chills, acceleration of pulse- 
rate, loss in body-weight, etc. The experiments that recently have been 
repeated so many times by Billroth. Weber, Fischer, Bergmann and a host 
of other investigators, give almost the same results; and fever U 
not only by the injection of putrid materials, but also by the produi 
tissue-metamorphosis congregated, for example, in an intlamed wound, 
though there be no trace of putrefaction. 4 

According to modern research, we know that traumatic fever is produced 

1 Allgemeine Zeitschrift fur Psychiatrie. Bd. xxv., p. 686. Berlin. 

s Sidney Ringer : The Influence of Alcohol, etc. Lancet. 
1866, p. 208. H. C. Gell and Sidney Ringer: The Influence of Quinine on th. 
perature of the Human Body in Health. ^Lancet. October 81, E 

8 Brown-Sequard : Soeiete de Biohgie. VoL i., p. 103. 1848. II Wji 
of Poisoning by Sulphuric Acid. Arehiv der Heilkunde. Hef: 2 .gnan : 

Cas d'Empoisonnement par TAlcool. Gazette des Hopitaux. N 

4 Venom seems to act in a similar manner. — Ca» of snake- (oobni I 
fully treated by sucking, liquor potassa), and brandy. John S 
16, 1870. 



THE DISEASES OF OLD AGE. 187 

in an analogous manner. The fluids thrown out from the surface of 
wounds, and loaded with products formed by destruction of tissue, pene- 
trate, by diffusion, through the walls of the lymphatics and veins, thus com- 
mingling with the blood. Thus it is they develop the febrile state by rea- 
son of this pyrogenetic power, the existence of which has lately been proved 
by experimentation. 

Experiments have likewise proved that the blood of a feverish animal, 
when injected into the veins of a healthy animal, induces fever. And even 
a rather profuse bleeding, which in a healthy individual has had the effect 
of producing a fall of temperature for a short period of time, may subse- 
quently produce a true febrile state. On account of the diminution of ten- 
sion occurring in the vascular system as a result of the loss, the products of 
the normal metamorphosis of tissue suddenly enter the circulation in great 
abundance, and there comport themselves after the manner of pyrogenetic 
substances. Such, at least, is the interpretation given by Bergmann and 
Frese, the investigators who conducted the experiments. ' 

It seems then to be established, that the majority of septic substances 
contained in pathological fluids have the effect of causing fever. But it is 
equally true that a certain number of this kind of substances have a dia- 
metrically opposite action upon the organism. Thus, for example, in the 
experiments of Weber and Billroth, the injection of putrid animal matter 
or putrid pus has very often determined a marked diminution in the tem- 
perature ; commonly this is followed in a short time by a more or less in- 
tense febrile condition, now persistent in character, and again, on the con- 
trary, progressively aggravated until death occurs, which, in the latter 
instance, generally ensues very quickly. 

It is difficult to absolutely predetermine what putrid matter will, when 
injected into the blood, produce fever, and what, on the other hand, will in- 
duce central algidity ; for, under the name of putrid or septic matter, are 
comprehended substances of the most varied chemical composition. It is, 
at least, very probable that the same substance which, taken at a given 
period of putrid fermentation, would cause fever, might, if used at a more 
advanced stage of the work of decomposition, induce the opposite result — 
algidity.. The principles whose presence in the putrefying matter may be 
determined by chemistry vary, of course, according to the nature of the 
substances whence they originated, and according to the different stages 
of putrid fermentation. Now, among these principles are some which, 
when separately injected into the blood, have the effect of lowering the 
bodily temperature. Such, according to the concordant experiments of 
Billroth, Weber, and Bergmann, are ammonia carbonate, butyric acid, am- 
monia hydrosulphate, and hydrosulphuric acid (sulphuretted hydrogen). If, 
then, there is a predominance of these agents over the pyrogenetic sub- 
stances in a fluid, we can readily understand what effect will be produced 
upon the organism by the injection or absorption of such a fluid. 

These data, taken from experimental pathology, are, we think, the key 
to a certain number of apparently contradictory facts that are observed in 
human pathology. 

There are, indeed, cases of septicaemia with fever, and others with cen- 
tral algidity. Occasionally, too, these seemingly opposite conditions may 
occur in succession in the same individual without the primordial phenom- 
ena being at all modified in their appearance. 

We may mention, in this connection, what is observed in cases of trau- 

1 Centralblatt, Na 2. 1869. 



188 CLINICAL LECTURES ON 

matic or spontaneous gangrene spreading over a large part of a limb. It 
has been shown, you know, that when the circulation of the blood has been 
completely arrested in a gangrenous limb, and when coagula have formed 
both in the arteries and the veins, the sphacelated portions may become a 
source of infection. Clinically we are already well acquainted with this 
fact, but the experiments of Kussmaul have placed this matter in the clear- 
est light. Under the skin of a limb thus apparently separated from the 
rest of the organism, he injected a certain quantity of iodide of potassium ; 
four hours later he detected traces of iodide in the urine. After this we 
may no longer doubt but that putrid matters from sphacelated parts can 
penetrate to the circulatory torrent. The phenomena of infection which they 
then induce sometimes manifest themselves by intense fever ; sometimes, 
on the other hand, by central algidity. We often notice within this hospital 
this succession of occurrences in cases of spontaneous gangrene, which usu- 
ally arise from an atheromatous or thrombic obliteration of the principal 
arterial trunks of a limb. If, in such cases, the patients resist infection 
for several days, and especially if the gangrene assume the moist form, the 
central temperature may progressively fall to 36 or 
Fahr.); in one case we even saw it as low as 34.. "5 ('.>4.1 Fahr. ). Here 
death occurred in the midst of symptoms of profound collapse : external 
algidity, cold sweat, almost imperceptible pulse, etc. 

How is it these substances are enabled to lower so rapidly and so con- 
siderably the central temperature ? It is supposed that they destroy a very 
large number of blood-corpuscles, or at least suddenly annihilate then- res- 
pirator power. In such cases, according to AYilhains' expression, 
or death of the blood is produced. Although they pn serve their pt 
character, the globules thus changed have lost their chemical j 
Should this alteration in the blood-disks be general, a rapid fall in temper- 
ature ensues. * 

Still, it is highly probable that, independent of this action, certain sub- 
stances affect the heart by paralyzing its movements. This happ 
the case of bile. "Whenever a certain quantity penetrai the blood, 

it simultaneously causes the heart to stand still and the t .re to 

fall (Leyden, Bohrig). Experimentation, to-day, has even . • far as 

to tell us what, among the very numerous constituents of the bile, are 
those which exclusively determine the slowing of the cardiac movements, 
and what are concerned with central algidity. 

Contrary to the ancient idea, we know that all of the bile — or at 
the principal fundamental constituents — passes into the blood in simple 
jaundice, such as that resulting from occlusion of the ductus communis 
choledochus. Now, in this spontaneous jaundice, as in experimental icte- 
rus, the elementary ingredients of the bile are found in the blood and ihe 
urine. In both instances, too, a slowed pulse and diminished of 
perature may be observed. 

Bohrig ' has proved that these results are due to the presence of the 
biliary acids ; injected alone into the circulation, they produce the same 
effects. 

Nothing like it, however, is caused by choleeterin, the coloring, or 
matters. By the sole fact of diminishing the number and strength of the 
heart's movements, the biliary acids may induce lowering of tl- 
ture. But Van Dusch and Kuhne have demonstrated thai 
sess the power of destroying the blood-corpuscles, and the I 

1 Archiv der Heilkunde. 1863, 



THE DISEASES OF OLD AGE. 189 

doubtedly contributes, in great measure, to produce a depression of the 
thermometric markings. 1 

A remarkable fall in the central temperature likewise occurs in the ma- 
jority of cases of ursemia. 2 

m. — After what I have just said to you concerning the mechanism by 
which lowering of the temperature is effected through the influence of the 
introduction of septic matters into the blood, you will not be astonished to 
find the same characteristic in certain organic or functional diseases of the 
heart. It is unquestionable that the majority of diseases which weaken the 
action of the heart tend to produce depression of the central temperature. 
"We can readily understand how flagging of the circulation, carried to a 
high degree, is a most unfavorable condition for the accomplishment of those 
chemical acts that maintain the bodily heat. It is also well known that 
when cardiac enfeeblement is carried to its utmost limits, as in syncope, 
the blood traverses the capillaries without undergoing any modification 
therein, and appears in the veins with the bright red color of arterial blood. 
Now in cases of this kind the central temperature falls, and is even markedly 
lowered in circumstances where matters are carried less far. 

Among the diseases of the heart itself that are accompanied by a dim- 
inution of the central temperature, I may mention, as an example, the case 
of rupture of the organ and extravasation of blood into the pericardium — 
a case we all saw in this hospital. One morning, in the dormitory, an old 
woman fell in syncope, and was immediately transferred to the infirmary, 
where we found her in deep lipothymia, which persisted nearly the entire 
day. A second syncope occurred just before evening, and death quickly 
ensued. During the long syncopal period between the two lipothymiss, 
the heart was feeble, frequent, and irregular ; the pulse almost impercepti- 
ble ; and the rectal temperature 36° (90.8° Fahr.). 

You are conversant with the fact that, incases of asystolism arising from 
organic diseases of the heart, there occur from time to time paroxysms 
characterized by feebleness and irregularity of the cardiac impulse, cyanosis 
and external algidity. During these attacks we have frequently observed 
the central temperature fall to 35° or 36° (95° or 96.8° Fahr.), and the par- 
oxysm once over, speedily returns to its normal standard. In acute peri- 
carditis and acute endocarditis, as we mentioned in our first lectures, we 

1 Yirch. Archiv, xiv. 

2 One of my pupils, Dr. Bourneville, has recently published a series of investiga- 
tions, whence it results that in uraemia — from whatever cause it springs (parenchyma- 
tous nephritis, pyelitis, cystic degeneration of the kidneys, calculous obliteration of 
the ureters, etc.), and whatever symptomatic form this blood-poisoning assumes 
(comatose, apoplectic, convulsive) — there is a constant lowering of the central tempera- 
ture. This fall increases as the nervous symptoms are aggravated, and, in some cases, 
the temperature has dropped below 30° (86 D Fahr.). In pueiyeral eclampsia, however, 
which some authors continue to ascribe to uraemia, Bourneville has observed a con- 
stant elevation of the temperature — an elevation that progressively increases from the 
onset until the fatal termination. 42° (107.6° Fahr.) has sometimes been reached under 
such circumstances. 

Besides, Bourneville has collected a certain number of observations relative to the 
modifications which the central temperature undergoes in cerebral apoplexy (hemor- 
rhage in, or softening of the brainy which confirm in every respect the results I have 
published. And further, having taken the hourly temperature in some apoplectic 
patients, he has demonstrated the influence, upon the thermometric curve, of the pro- 
duction of new hemorrhagic foci, or the effusion of extravasated blood into the ven- 
tricles. (See Bourneville : Etudes Cliniques et Thermometriques sur les Maladies du 
Systcme Nerveux. Paris, 1873.) 



190 CLINICAL LECTURES ON 

sometimes notice a rise, sometimes a marked lowering of the central tem- 
perature. The same occurs in peritonitis. YVunderlich's observations are 
ample confirmation of the results we have thus far arrived at 

At a cursor j view it might appear strange to see a phlegmasia which some- 
times occupies a very large extent of surface — the whole of a serous mem- 
brane — induce a fall in the central temperature. Such is the case, how- 
ever : thus, pericarditis is superimposed upon lobar pneumonia ; it might 
be imagined this combination would result in a hyperpyretic ascent of the 
curve; but this does not occur. The curve either remains stationary, or, 
in the majority of cases, judging from oft-repeated observations, there is 
an unusual depression of the tracing. The production of such a depre- 
during the course of a pneumonia which up to that time has been regular, 
has often induced us to examine the heart with unusual care, and thus to 
recognize the existence of a pericarditis which, otherwise, would wholly 
have escaped us. Diaphrugmatic pleurisy f pneumothorax fr 
traumatic peritonitis — that arising from perforation and internal strangulation — 
likewise generally cause, momentarily at least, lowering of the central tem- 
perature. True, this is not an invariable result, but it is. nevertheless, 
quite a common one. Let me add that, in such cases, the central algidity 
may occasionally persist, or even increase until death, whereas in other in- 
stances it may give way to an excessive rise in temperature. 

However this may be, we need no longer be astonished to find, if we 
refer to the results of experimentation, a more or less violent irritation of 
the serous membranes, the peritoneum in particular, inducing such effects. 
You know very well that a blow over the epigastric region, the ingi 
of cold drinks when the body is covered with perspiration, 1 may bring about 
sudden death, apparently through the mechanism of syncope. Now, Brown- 
Sequard has shown that excitation of the semi-lunar ganglia" results in the 
production of syncope. According to him, this excitation of the ganglia is 
transmitted by the spinal cord to the bulb, is then reflected upon the pnea- 
mogastrics, which, irritated in their torn, cause the heart to stop in diastole. 
"When not carried so far as this, the excitation of the great sympathetic 
plexus niay determine a permanent diminution in the ■ and hence 

produce a more or less enduring kind of syncopal (Upothymic) condition, 
along with permanent lowering of the temperature. 3 

It is undoubtedly by an analogous process that great concussion of the 
nervous system first manifests itself by a syncopal condition with on 
algidity, accompanied or not by subsequent reaction. 

Magendie has proved by experiments, which, Claude Bernard has con- 
firmed, 4 that all severe irritation of the peripheral nerves — such, for example, 
as the crushing of a limb entails — has the effect of lowering cardiac pres- 
sure ; the researches of Mentegazza inform us that in such cases the cen- 
tral temperature is diminished. 6 

Following certain traumatic lesions of the cord, Brown-Seqnard has ob- 

1 Consult on this subject the interesting memoir of M. A. Gtaerard: Bui lea 
denta qui peuvent succeder a Tlngestion des Boissoiis Froides. Annalea d'Hyg 
Vol. xxxvii. Paris. 1842. 

2 Of the solar plexus. — L. H. H. 

3 See Brown-Sequard : Archives de Medecine. Vol. ii.. pp. 44 \ 4^4. IS 

tures on Physiology and Pathology, p. 1 ol). Bernstein: H -ympa- 

thicus-Reizung. Centralblatt, Xo. 52. 1863, Ibid., No. 16. 1m>4. Eulenb. • 
Guttman: Patholog. des Sympathicus, in Archiv fur PBjchiatrie. Bd, ii.. Heft 1. 
1809. 

4 Lecons, etc. Vol. i., p. 20 7. 5 Schmidt's Jahrb. I,,l! 



THE DISEASES OF OLD AGE. 191 

served profound collapse, complete suspension of reflex action, and the 
passage of red blood into the veins. At the same time there is a fall in the 
central temperature. 

IV. — We have just considered the principal circumstances in which the 
central temperature is lowered. Now, generally, when this thermic de- 
pression occurs abruptly, it manifests itself externally by coldness of the 
surface of the body, and by a train of other alarming symptoms. These 
signs, taken collectively, have been designated under one name, collapse, by 
Thierfelder * and Wunderlich, to whom we are indebted for a remarkable 
study on this clinical point — a point, it must be acknowledged, of which we 
have been too neglectful. 2 

But collapse may likewise be produced in cases where the central tem- 
perature remains normal, or even rises above the normal limits ; and ac- 
cording as one or the other of these different forms is exhibited, the prog- 
nosis and the therapeutical indications will be found strikingly changed. 
Collapse is sometimes an almost certain forerunner of a fatal termination ; 
sometimes, again, it undoubtedly indicates a very grave state of affairs, but 
one that the well-directed resources of the art may, perhaps, carry to a fa- 
vorable issue. Finally, collapse is at times only an exaggeration of the phe- 
nomena which are nearly always observed, to a certain extent, when some 
varieties of febrile disease terminate with a rapid and favorable deferves- 
cence. 

From this simple expose it should be immediately apparent to you all 
how interesting to the clinician the study of collapse must prove, since, 
every time this group of symptoms is presented to him, there is a problem 
to be solved, a prognosis to be determined, a peculiar series of therapeutic 
means to be employed, and, let us add, all these within the barest limits of 
time, for the symptoms of collapse may only too soon terminate fatally. 

These phenomena are very commonly observed in the most diverse dis- 
eases of old age, and in those who are weakened by pre-existing maladies or 
by alcoholismus. But it is when supervening in the course of acute febrile 
diseases that collapse especially deserves attention. It is under such cir- 
cumstances that we desire to study it with you, and endeavor to determine 
its principal characteristics. 

Let us suppose a case of lobar pneumonia, and select a well-marked 
example. Up to the sixth or seventh day all has been in accordance with 
the established precedent ; the pneumonia is very severe, but it has devel- 
oped regularly ; the temperature is 39° or 40° (102.2° or 104 Fahr.), and 
the external phenomena of the febrile state are well developed. Suddenly, 
in the space of a few hours, the whole aspect changes ; the face is altered, 
the eyes deeply sunken, the cheeks and nose pale and icy ; the extremities 
are cold and cyanotic ; the body is covered with cold swea,t ; there is 
great prostration of the forces, and occasionally delirium may set in ; the 
cardiac impulse is feeble and irregular, the sounds seem dull and distant ; 
the pulse is thread-like, now accelerated, now retarded ; the respirations 
are rapid and deep. 

What is the signification of this very alarming ensemble of symptoms ? 

The exploration of the central temperature in such a case furnishes us 

1 Archiv fur physiol. Heilkunde, 14te Jahrgang. Heft 2. June 15th. 

2 In an excellent article, Chaleur, in the Nouveau Dictionnaire de Medecine et de 
Chirurgie Pratiques. (Vol. vi., p. 808. 1867.) Hirtz has brought into prominent no- 
tice the interest which attaches to the study of collapse. 



192 CLINICAL LECTUEES ON 

most valuable indications: first, if, at the very moment when the phe- 
nomena of external algidity are being produced, the central temperature 
is maintained at a high degree, or even rises to a hyperpyretic standard, 
death is certain. Indeed, dissolution has already begun. Soon it will no 
longer be a matter of doubt ; the pulse will continue to increase in fre- 
quency, and laryngotracheal rales quickly appear. Second, if, on the con- 
trary, at the same time the symptoms of collapse manifest themselves, the 
central temperature undergoes a marked diminution, or even descends to 
normal or slightly subnormal limits, the situation of the physician is more 
difficult, for at times the fatal termination may be already in preparation, 
and occur without much delay ; and again, on the other hand, convalescence 
may set in at the end of a few hours, and a bad prognosis, hastily given, 
will thus receive an express contradiction. It behooves us, therefore, to take 
into most serious consideration the indications offered by the other phe- 
nomena which accompany a diminution of the central temperature. 

When collapse is but the exaggeration of the ordinary symptoms of a 
rapid and favorable defervescence — when, at the same time that the central 
temperature falls, the respiratory movements and arterial pulsations be- 
come slower and regular, the prognosis is good, even though some alarm- 
ing symptom, such as violent delirium, supervene. 1 

When, on the other hand, the central temperature falls, and the fre- 
quency of the pulse and respiratory movements continues or inn 
situation is very grave indeed. Death will very soon supervene. d< 
every effort that may be made. And although we were but recently led to 
give a favorable prognosis, even when intense delirium was an accompani- 
ment, yet here we must maintain an equally unfavorable one, in spite of 
the defervescence producing a feeling of comfort in the patient. 

Such was the case of a woman, fifty-four years old, enfeebled by uterine 
carcinoma, who had an attack of lobar pneumonia — a case we had in 
very wards. About the seventh day of the pneumonia, at the moment when 
rapid defervescence occurred, this woman experiei. uliar sensation 

of well-being, which has deceived many of you, but which very soon suc- 
cumbed to the death-struggle. 

This is the collapse, which in croupous pneumonia takes place at the 
period of defervescence as the most usual occurrence. But the same group 
of symptoms can appear at any stage of the disease. 

At the acme of the malady, collapse results in the majority of c 
from some complication, such as pericarditis, violent diarrhoea ; or rather, 
in the aged, it appears from too marked an action of a drug, as tartar emetic 
or digitalis. 

The prognosis you will give varies very much in this class of c 
It depends particularly upon the influence of the means employed to com- 
bat the complication, or to repair the damages caused by ill-timed medica- 
tion. 

Again, collapse may manifest itself from the commencement of a pneu- 
monia ; in such cases it is usually transitory, soon giving way to a more or 
less marked reaction ; at other times, however, it persists during the whole 
course of the disease, which then commonly ends most unfavorably. 

This algid pneumonia is quite rare, even among the ly debili- 
tated subjects whom we meet with in such great numbers within 
walls. Many of you, however, have perhaps observed a remarkable exam- 
ple of this in our wards. The woman, L , seventy-oiu :' age. 

1 Weber: Med. -Chirurgical Transactions. Vol. xlviii. l v 



THE DISEASES OE OLD AGE. 193 

when attacked with lobar pneumonia, presented from the onset, and during 
the whole period of the disease, a series of symptoms which made it resem- 
ble cholera. The extremities were cold and extensively cyanotic, the face 
was livid, the eyes deeply sunken, and the voice very faint. There was no 
diarrhoea. The alvine evacuations were rather scanty ; the urine was pale, 
diminished in quantity, containing quite a large proportion of albumen. 
The rectal temperature osculated between 38° and 38.4° (100.4° and 101.1° 
Fahr.), never reaching 39° (102.2° Fahr.). The pulse, feeble and almost 
imperceptible, was between 100 and 108. At the autopsy, the lower and 
middle lobes of the right lung, throughout their whole extent, presented 
the most classical characteristics of red and gray granular hepatization ; and 
the lung itself weighed nearly one thousand grammes more than the left (2 
pounds 3^ ounces avoirdupois). The kidneys offered no appreciable change. 

This variety of collapse constitutes one of the characteristics of the sideral 
form of the majority of pestilential diseases, contagious and infectious fe- 
vers ; thus, we observe it in yellow and typhus fever 1 and in the plague ; it 
is also met with in paludal (malarial) poisoning. 2 

I have often seen it in the small-pox of the aged, where, as you know, 
it frequentty assumes the hemorrhagic form. In such cases, at the very 
moment when the blackish pustules appear upon various parts of the body, 
the extremities become cold and cyanotic, the prostration of the forces 
reaches the utmost limit, and the temperature in the rectum varies between 
36° and 37° (96.8° and 98.6° Fahr.). 

I am far from having exhausted the subject I purposed to discuss before 
you, but I fear to weary your attention by multiplying examples ; besides, 
I have said enough, at least so I hope, to demonstrate to you the exceed- 
ing interest which attaches to thermometric studies in the clinic in general, 
and especially in the case of old age. 

1 Charcot : Articles Typhus Fever, The Plague, Yellow Fever, in the fourth vol- 
ume- of Elements de Pathologie Medicale. By A. Requin. Paris, 1868. 

" In algid pernicious fever. Griesinger • Traite des Maladies Infectieuses, p. 64. 
Paris, 1868. 

13 



194 CLINICAL LECTUBES ON 



LECTUKE XXII. 

SENILE PNEUMONIA. 
Summary. — Introduction — Morbid Anatomy — Symptoms — Etiology. 

Gentlemen : — In our northern climate, diseases of the respiratory organs 
are the most common and fatal of the diseases of old age. 

That we niay study this class of diseases intelligently, it is necessary 
that we should be familiar with some of the more important anatomical and 
physiological differences in the lungs in adult life and in old age. 

The rarefied condition of the lungs in the aged, their increased light- 
ness, the dilatation and rupture of the air-cells, their diminished elasticity, 
the obliteration of large numbers of their capillary vessels, and the diffu- 
sion of carbonaceous matter throughout their substance, tend to modify the 
pathological changes which occur in the pulmonary diseases of the aged. 

The lungs in fleshy old people are of an ashy gray color, studded with 
black spots and lines. The surface of the pleura is less moist than in 
adult life. Externally the lungs resemble those of adults ; but they crepi- 
tate less and have a more elastic feel. The fissures between the lobes 
change their position, so that in the left lung the upper lobe is in front and 
the lower behind, and in the right lung the middle lobe projects down- 
ward, the lower one rising behind it, so that it forms a considerable por- 
tion of the summit of the lung : thus, pneumonia of the apex may really 
have its seat in the lower lobe. Microaxpicauy the air-cells are about 
double the size of normal adult lung-cells. 

In emaciated old people, though the lungs are much the same as in the 
fleshy, they cannot be perfectly inflated ; they are bathed in serum ; the 
and lines are more distinct, and they crepitate much It 

Again, the lungs of the very aged may present a livid appearance, the 
apex being larger than the base. Their surface is uneven and look- 
they were "crumpled," and they are surrounded by a large quantity of 
fluid, which fills the space caused by their wasting : they cannot be fully 
inflated, and the respiratory murmur is very feeble. They lie close to the 
vertebral column. Their specific gravity is much less than that of the 
adult lung, and the lobes are occasionally attached to one another by pedicles. 
The alveolae have no definite form, and* the cells are very large. The bony 
thorax accommodates itself to these atrophied, shrivelled lungs. 

With advancing years the vital capacity volume d< nfl ^ith tolerable 

regularity. The rate of diminution has been estimated to be about one 
and a half cubic inches each year. 

During each hour a healthy adult exhales about one thousand three 
hundred and forty cubic inches of carbonic acid ; now. between I 



THE DISEASES OF OLD AGE. 195 

sixty and eighty the amount, in men, falls to about nine hundred and 
thirty cubic inches each hour, and in very old men it has diminished even to 
six hundred and seventy. 

The same physiological difference exists between the sexes in old age 
as in other periods of life; thus, women in the sixties exhale only six hun- 
dred and seventy cubic inches of carbonic acid an hour, and this continues 
to decrease in a proportion similar to that in old men. 

The precise changes which occur in the interchange of gases in the 
lungs in old age are not very well understood. 

The respiratory activity, the depth, and the force of the acts, all are 
much less in old age than in middle life; and the predominance of venous 
blood is a marked feature of old age. 

Finally, what the French call "besoin de respirer" — want of breath — in- 
creases perceptibly as years pass. 

With these facts before us, let us study the anatomical changes which 
take place in the pneumonia of old age. In our climate it is the most fatal 
inflammatory disease of the respiratory organs in the aged. The mortality 
rate in those over sixty years is about eighty per cent. For this reason, 
and on account of the very great differences in the disease when it occurs 
in adult life and in old age, I shall enter into its history somewhat in detail ; 
at least, I wish to make pneumonia in old age a subject of special impor- 
tance in the few lectures which I shall add as a supplement to the inter- 
esting and instructive lectures of Professor Charcot on Diseases of Old 
Age. 

Its morbid anatomy may be divided into three stages : a stage of en- 
gorgement, of red hepatization, and of gray hepatization. In the aged the 
morbid changes usually begin in the upper lobes, the disease extending 
downward — the reverse, you remember, of what occurs in adults. 

Engorgement. — This stage resembles that of the adult pneumonic lung 
— the dark red color, the firmness, the pitting on pressure, the doughy 
feel, and increased weight, all are here. They do not sink in water, the 
loss of crepitation is far greater than in adult life — indeed, often entirely 
absent. 

On section, a bloody serum exudes, and flows much more freely from 
the cut than in adult pneumonia. It is now (comparatively) very friable. 

This is the only change which you will find in many cases of " sudden 
death " in pneumonia of the aged. 

It is often called congestion of the lungs, and by its gross appear- 
ance alone it is difficult to differentiate between this stage of pneumonia 
and congestion ; but a microscopical examination reveals, in pneumonia, 
the air-cells filled with a markedly viscid fluid, which, on the addition 
of alcohol, coagulates into an amorphous, granular substance, containing 
a number of red blood-globules. The diminution of the lumen of the 
air-cells by the enlarged capillaries is not well shown in senile pneu- 
monia. 

In pulmonary oedema the fluid in the air-cells is simply serum ; in pneu- 
monia it is an inflammatory exudation. 

In the stage of red hepatization the lung is of a deep red color, darker 
than is usual in adult life, no longer crepitates, and' has a distinctly 
" marbled " appearance, heightened by the dark lines and dots that are 
present in its normal condition. 

The color is sometimes a bright blue or black. The lung sinks in 
water with a rapidity proportioned to the degree of consolidation, but it 
rarely falls to the bottom of the vessel, indeed, it frequently remains near 



196 CLINICAL LECTUHES OX 

the surface ; this lightness in the second stage of senile pneumonia is ex- 
plained by the rarefied condition of the lungs in the aged. 

On section, the cut surface may present either a granular or a non- 
granular appearance. The granules are much larger than is usual in pneu- 
monia at any other time of life, and, when not irregularly developed, they 
exhibit a tendency to commingle. Bloody serum exudes from the surface 
of the cut. 

Red granular hepatization is very much more common in old age than 
the non-granular, and the friability is much less than in adults. 

A microscopical examination shows the large, irregular air-cells to be 
filled with organized fibrin, red blood-globules, leucocytes, and changed 
epithelial cells. 

In the stage of gray hepatization or suppuration, the lungs are still con- 
solidated. 

On section, the cut surface presents a marbled drab, or " granite " look, 
and a copious flow of yellow, opaque pus exu.i 

There is more friability than in the second stage, and the lung breaks 
down on slight pressure, which reduces it to a grayish pulp. 

The microscope shows the presence of a greater number of leucocytes, 
and the young cells to have undergone fatty degeneration; the fibrinous 
plugs having disintegrated, the outlines of the granular elements within 
the alveoli are indistinct. 

These processes may terminate in resolution, gangrene, or abscess. 

When resolution occurs, the alveolar contents undergo such a fatty or 
mucoid degeneration that they are readily absorbed. 

Pigment, either from the blood or the interlobular connective tissue, 
often stains the masses, and appears in the expectoration. The lung i - 
gray-white in color — never granular — and a viscid, purifonn fluid can be 
squeezed from the cut surface. 

Senile pneumonia terminates in gangrene much mart frequently than 
adult pneumonia. 

You may find all or part of a lobe of the lung gangrenous. "When 
partial, the gangrene may be limited by an inflammatory zone, or diffused 
irregularly. 

The gangrenous cavities, when near the surface, often cause sloughing 
of the adjacent pleura, and in nearly all cases the lung-cavity contains a 
quantity of blackish green, fetid pus. The walls commonly consist of a 
shreddy material, and vascular bands pas the cavities. Myriads 

of bacteria are found in the fluid contents. 

The rarefied condition of the lungs in old age seems to favor the de- 
velopment of those small abscesses that are so common after a senile 
pneumonia. We occasionally find them interspersed throughout the con- 
solidated tissue, several of the alveoli intercommunicating. 

Large abscesses may break into a bronchus and establish a vomica, and, 
if superficial, may lead to pyopneumothorax. An external fistulous opening 
never occurs in advanced life. Large ftbfi ie result of the c 

cence of several smaller ones, containing, besides pus. pulmoni 
are rare in old age compared with the disseminated small om - 
abscesses are preceded by intercellular oedema. 

In old age, though the right lung is more frequently involved, the 
difference is far less striking than in adult life. Some obsef 
that sthenic pneumonia generally occurs on the right, and typhoid on the 
left side. ■ 

Senile pneumonia is invariably accompanied by inflammation of the 



THE DISEASES OF OLD AGE. 197 

minute bronchi, so that it may be difficult to differentiate between a catar- 
rhal and a croupous pneumonia. The pulmonary pleura is much less fre- 
quently affected in old age than in adult life. 

The lymphatics of the lung are choked with fibrin, red and white blood- 
globules, and a few endothelial cells ; while the deeper lymphatics contain 
products identical with those of the alveoli. 

Etiology. — The predisposing causes of senile pneumonia are : the age- 
degenerations, persistent bronchitis, and passive congestion from valvular 
and other diseases of the heart. 

Occupations where sudden changes of temperature occur, and hence, 
climates where a like condition is present, predispose to its development ; 
all enervating habits, poverty, intemperance, and dyscrasiae, act as power- 
fully in old age as in adults. From November until May nearly nine- 
tenths of the recorded cases of senile pneumonia have occurred. 

Bright's disease, pyaemia, and septicaemia are among its predisposing 
causes ; but the last two rarely occur in advanced life. 

A recumbent position, long continued, may lead to pulmonary hyperaa- 
mia, and thus predispose to pneumonia in the aged more so than in adult 
life. 

Sex is not so markedly prominent as a predisposing cause of senile 
pneumonia as at other periods of life ; indeed, the cases are pretty equally 
divided between old men and women. 

The most frequent exciting cause is cold ; and dry, sharp cold seems to 
act, judging from reliable statistics from hospitals for the aged, much 
more powerfully than moist cold, which rather induces bronchitis. 

Fracture of the ribs, pleuritis, and pericarditis excite pneumonia ; and 
it is noteworthy to observe how often, in the aged, such an accident as in- 
jury to the hip-joint, for instance, is followed by a pneumonia. It must, 
I think, be reckoned among the exciting causes, since, even as soon as 
four hours after the receipt of the injury, the disease is sometimes estab- 
lished. 

Lastly, uraemia and certain atmospheric influences, malarial and septic, 
excite pneumonic inflammation, and " sewer-gas " pneumonia is quite fre- 
quently developed in advanced life. 

Symptoms. — Senile pneumonia commences very insidiously, and usually 
runs a latent course. 

In a few cases it commences with well-marked symptoms in the midst 
of perfect health, and without any apparent existing cause ; or, as in the 
adult, flying pains in the limbs and chest, occasionally epistaxis, loss of 
appetite, and a feeling of general 'malaise, may be the precursors of its 
development. 

When intercurrent, senile pneumonia is always latent. 

It may begin with a protracted attack of shivering — rarely a distinct 
chill ; when an old person has a distinct chill, pneumonia almost invari- 
ably follows ; for, though less frequent, it is yet more important than in 
adult life. The same may be said of pain in the side. 

According to statistical records from that vast asylum for the aged — 
The Salpetriere — it is in March and April that these two symptoms almost 
always occur, and then the disease assumes the sthenic type. 

Again, when there is no shivering or pain — which occur in only about 
half the cases — the onset may be marked by a very slight increase in, or 
irregularity of, the movements of respiration, a slight elevation of tempera- 
ture, a feeling of great exhaustion, and a short, hacking cough. In some 



198 CLINICAL LECTURES OX 

cases even all but the feeling of weakness are absent. It mar be ushered 
in by nausea, vomiting, diarrhoea, and collapse. 

When an aged person, suffering from chronic bronchitis or asthma, de- 
velops a pneumonia, you will very often observe that the cough and diffi- 
cult breathing which were induced by either of these conditions, undergo 
remarkable diminution, and the aged patients are scarcely ill ; they get 
up, walk about as usual, perform their meagre daily work, he down on 
their beds feeling a "little tired," and suddenly expire. You meet such 
cases most frequently when chronic cardiac or cerebral disease coexist, al- 
though they do not necessarily cause a latent pneumonia. 

When not latent, senile pneumonia, once established, progresses with 
the following symptoms. 

The respirations are accelerated ; but, as old j^eople rarely com- 
plain of dyspnoea, you must count the chest-movements very carefully to 
recognize the change. There may be a cough, although at times it is so 
slight as to escape the notice of the physician, nearly always that of the 
sufferer. 

There is pain in the head, usually in the frontal region ; and this pain 
ma} r be followed by a mild delirium, especially toward evening, there being 
usually more or less disturbance of the intellect, while stupor or 

a coma, from which it is momentarily impossible to arouse the patient, 
comes on and continues throughout the disease. 

The face is flushed, sometimes more so on the side of the inflamed lung 
than on the other. 

The pulse is accelerated, the temperature is elevated ; and in all c 
on taking the temperature, the thermometer should be inserted in the rec- 
tum, for, as Charcot Bays, in the aged there is v* ry often a marked difl 
ancy between axillary and rectal thermometry, the latter only showing the 
true heat of internal viscera. 

There is great prostration, and the appetite is impaired, while thin 
increased. 

I shall now consider the individual Bjmptoma more in detail, and 
separately. 

By far the greater number of pneumonic patients who are advanced in 
life, cough ; and the cough, although in the main short, hacking, and pain- 
ful, yet undergoes greater variations in intensity, frequency, and character, 
from the fact that in old age pre-existing pulmonary or bronchial affections 
are so very common. 

Expectoration, — In old ag< ration d ir early, and. 

even when it does, is liable to sudden suppression. First scanty, gray, and 
frothy, then yellow or " catarrhal,*' it finally may become reddish, glutinous, 
or viscid. The red color is never so marked as in adults ; but 1 '. 
sputa may accompany acute senile pneumonias whose onset 
— these are fatal cases. In the majority oi cas uta resemble I 

of bronchitis, the color being opaque, yellowish green. Purely puriforni 
sputa never occur in the pneumonia of old age. 

Expectoration is always difficult, and is even absent in asthenic, masked 
forms of the disease ; it is rare to see classical variations in the sputa of the 
aged, such as we witness in those of adult life. Toward the close of the 
disease the expectoration becomes prune-juice in color ; but a choc 
looking serous sputa may occur soon after the onset, and i 
symptom, denoting, as it does, a depraved-blood conditio: 
pneumonia." 



THE DISEASES OF OLD AGE. 199 

A watery, blood-stained, or prune-juice expectoration indicates either a 
severe and dangerous form of pneumonia, or pulmonary congestion and 
oedema. 

The reason of the non-appearance of the viscid, pathognomonic sputum 
in pneumonia of advanced life is the rapid transition of the stages— puru- 
lent infiltration taking place early. 

A microscopical examination of the sputum reveals all the elements de- 
scribed in its pathology as filling the alveoli, and sometimes it affords one 
of the chief means of its diagnosis. 

In asthenic typhoid pneumonia, where the expectoration is slight, it 
ceases altogether with increasing prostratio?i. The sputa contain an excep- 
tionally large amount of sodium chloride. 

Finally, the appearance of creamy, abundant sputa on the day of crisis 
does not hold in old age, since expectoration may be catarrhal from the on- 
set, and throughout its course. 

The rectal temperature rises to 103° F. or 104° F., sometimes higher, on 
the first days. Except by the temperature range it is often difficult to 
determine the exact day of the invasion of senile pneumonia. With daily 
morning and evening oscillations of a degree or a degree and a half, it con- 
tinues for three or four days at about the initial point. The rise in tem- 
perature does not begin for several hours after the initial chill, if a chill 
occur. 

The temperature may rise progressively, with slight intermittent remis- 
sions ; or it may suddenly fall, the tracing giving an almost perpendicular 
line. Both these occurrences are common in senile pneumonia, the first 
ending in death in the vast majority of cases ; while the second, called the 
defervescence, tends sometimes toward recovery, sometimes toward dissolu- 
tion. 

When the onset can be approximately estimated, the temperature will 
be found to be highest on the third day, unless fatal defervescence occurs. 

The pulse in the aged is normally more frequent than in adult life. In 
old men the average normal pulse is froin sixty to seventy beats per min- 
ute, and in women from sixty-eight to seventy-eight. This is the rule, al- 
though in a few instances you may find marked slowness of the pulse-rate 
in healthy old men and women. Hence, in senile pneumonia the pulse 
does not afford reliable indications ; for the rate, in this disease, might be 
only fifty, and yet this might be a rapid pulse in this particular instance. 
When normal, the pulse is from seventy-three to seventy- eight ; you rarely 
find any increase when the pneumonia begins. 

On account of the arterial changes in old age, it is best to count the 
pulse at the heart. 

In the pneumonia of adults the pulse is " full," but in old age the pulse 
has, normally and in disease, a fictitious hardness ; when the heart is 
intermittent the radial pulse may not represent any intermittency or ir- 
regularity, and on the other hand it may become feeble and intermittent 
while the heart is normal and acting with regularity. 

The action of cold to the surface in the aged is very quickly indicated 
by the radial pulse, diminishing its volume and strength ; so, if the pulse 
at the wrist be taken, it should be from the hand that has been under the 
bed-clothes. 

Finally, although the pulse may rise to one hundred and twenty beats 
or more per minute in senile pneumonia, still it must be regarded as an 
untrustworthy g-uide. 

TJie respiration. — In old age the work of the respiratory organs seems 



200 CLINICAL LECTURES ON 

to diminish with that condition of the lungs of which I have previously 
spoken. The diaphragm is the chief agent in respiration. The scaleni 
muscles and the sterno-cleido-mastoid becoming nearly useless, you will 
very frequently notice the head to be thrown back during inspiration, and 
the whole act of inspiration is imperfect and more or less difficult. 

In inspiration in the aged, the enlargement of the chest is chiefly verti- 
cal ; there is no lateral movement whatever. Expiration is sudden and 
rapid, as a rule ; the whole act, however, is of a "panting" character. The 
number, on the average, of respirations, is twenty-two ; and inspiration is 
to expiration as six to eight or nine. 

Very often the inspiratory movements, in old age, are " jerky M and in- 
terrupted, the lung becoming expanded only after a succession of efforts. 
This occurs in perfectly healthy individuals. 

There is a marked diminution in the vital capacity of the lungs of the 
aged. 

Again, the altered condition of the mucous membranes of the whole 
respiratory tract, from imperfect vascular supply, probably interferes with 
the proper excretion of aqueous and other vapors. For this reason pul- 
monary oedema is readily set up in senile lungs. The proper amount of 
excretion does not take place, and hence the fetid breath which is met with 
in so many old people. 

As has been mentioned, old people with pneumonia rarely complain of 
difficulty in breathing ; and you may notice the acceleration in the num- 
ber of respirations oftener, by palpating the chest than by direct obser- 
vation, for the respirations may vary from thirty to seventy per minute, and 
yet no actual dyspnoea exist. 

As in the adult, the degree of dyspnoea is directly proportional to the 
extent and severity of the pneumonic process, except in pneumonia of the 
apex, when there is always intense dyspnoea, so much so that severe dysp- 
noea in the aged should always direct you to a physical exploration of 
that part of the chest. 

" Catchy " breathing — a mere exaggeration of what is physiological in 
old age — is one of the most frequent forms of abnormal respiration, in the 
pneumonia of advanced life. 

When dyspnoea is very intense, and the pneumonia is at the base of the 
lung, it tells of nervous exhaustion, and is very serious. 

As you will remember, the general causes of dyspnoea in pneumonia 
are the diminution of the breathing surface ; the influence of the fever ; the 
pain, which is exacerbated by movements ; the enfeebled heart-power ; and 
the greater demand for oxygen, on account of the rapid tissue-metamor- 
phosis. 

Pain. — Even in pleuro-pneumonia of the aged, pain is never very in- 
tense ; it is rather an uneasy, dull feeling, occupying no particular 
and very frequently is diffused over the whole chest. 

Tenderness on palpation or percussion is not so marked as in the 
adult. 

Pain, if present in senile pneumonia, is referred to various local: 
the pit of the stomach, the region of the xiphoid cartilage, the nipple, the 
loins, the hypochondriuni, or even the side opposite to that which is the 
seat of the pneumonic process ; but it is always anterior. In pneumonia 
at the apex it is transitory or completely absent. 

In "typhoid" pneumonia there is no pain; but, as the disease pro- 
gresses, a sense of " oppression M occurs, which increases with the inert 
weakness. 



THE DISEASES OF OLD AGE. 201 

One side of the face, more than the other, has a " mahogany " colored 
flush upon it, not diffused as in typhus fever, but as a circumscribed spot. 
This flush is often the first objective sign of senile pneumonia. The heat 
of the skin is greatest in the morning. Three or four days from the onset 
of the pneumonia, herpetic eruptions appear upon the cheeks, lips, and 
nose. 

If the lips become blue, it denotes vaso-motor disturbance, and is a 
very grave sign. As the disease advances, the face loses this dusky hue and 
becomes sallow — a very dangerous symptom — and the surface-heat gives 
place to a cold, clammy perspiration. 

At my next lecture I shall continue the consideration of the objective 
symptoms and physical signs of senile pneumonia. 



202 CLINICAL LECTUKES ON 



LECTURE XXIII. 

SENILE PNEUMONIA— ffontfntutf. 

Summary.— Symptoms — Physical Signs — Differential Diagnosis — Prognosis — Treat- 
ment. 

Gentlemen : — Headache usually lasts throughout an attack of senile 
pneumonia, and is apt to be accompanied by delirium of a mild type, 
when the apex is the seat of the inflammatory process. In asthenic, typhoid. 
or " nervous " pneumonia, there is low, muttering delirium, and a constant 
desire to get out of bed. These symptoms, however, do not of themselves 
indicate any serious cerebral disturbance. 

Of the symptoms referable to the alimentary tract, anorexia is the most 
constant ; and, while patients do not express a desire for drink, they yet take 
with avidity the fluids which are put to their lips. 

The tongue at first is whitish ; later on it becomes dry. shrivelled, and 
coated with a thick, brown fur, and is protruded with difficulty. The 
teeth, gums, and inside of the cheeks are likewise covered with thick, brown 
sordes. 

The stools are dry. and, as a rule, the bowels constipated. 

Some think that the Hver undergoes passive hyperemia during a pneu- 
monia, the mechanism being the same as in certain cardiac derangen 
and thus they account for the jaundice which so frequently accompanies 
senile pneumonia. But it is more in accordance with to-day*! pathology 
to regard the jaundice as of hematogenous rather than of hepatogenous 
origin ; caused, in other words, by a change in the blood itself, the direct 
result of the pneumonic process. 

Jaundice is more frequent in cases where the pneumonia is located at 
the apex. 

The urine is scanty, dark red or brown in color, and of high specific 
gravity. Bile-pigments are found in it. There is an increase in urea, and, 
on cooling, the urine becomes turbid from precipitation of the urates. The 
most characteristic change is the great diminution of chloride of sodium. 

Albumen may be present, and the higher the temperature, the more 
albumen may we expect to find, other things being equal. 

The signs which indicate the mode of termination of senile pneumonia 
vary. 

If a case is tending toward a fatal termination, the face becomes sallow ; 
the skin cold and clammy ; the ala^ nasi and extrinsic muscles of respiration 
are called into play ; the heart becomes feeble, rapid, irregular and inter- 
mitting ; the temperature either rises rapidly or falls quickly and continu- 
ously ; the inspirations are gasping, there are groat apathy and somnolence, 
and gradually coma comes to usher in the fatal issue. You may sometimes 
hear, at a distance from the patient, the rales which result froni that a 
of the lungs which comes from heart-failure. 



THE DISEASES OF OLD AGE. 203 

When resolution occurs in senile pneumonia, it is generally by crisis. 
The temperature falls suddenly, sometimes below normal ; there is a return 
of the appetite, a general feeling of returning comfort, and if there has 
been prune-juice sputa, the red color disappears and a catarrhal expectora- 
tion takes its place. This, however, is not a very frequent termination of 
senile pneumonia. 

Convalescence is slow, months elapsing before complete recovery is 
reached. 

If the pneumonia terminates in gangrene, typhoid symptoms appear 
very early. The face is generally pale, sometimes of a deathly hue ; the eyes 
are sunken, the breath is fetid, and the whole body emits a cadaverous odor. 

The sputum, if present, is of a blackish green color, of a putrid odor, 
and contains shreds of decomposed and decomposing lung-substance. 
If pulmonary gangrene is a sequel of pneumonia, death occurs with symp- 
toms of the profoundest collapse, usually within five days from the time of 
the initial chill. 

The formation of abscesses in senile pneumonia is never evidenced by 
any well-marked symptoms. There may be rigors and hectic ; the expec- 
toration may become purulent, copious, and of a grayish tint, sometimes con- 
taining fibres of pulmonary tissue, with the physical evidences of a lung- 
cavity. 

Finally, before studying the physical signs of senile pneumonia, there 
remains a not unimportant variety which is called bilious 'pneumonia — an 
unfortunate name, since the term bilious is too often, at the present day, 
applied to any group of symptoms that seem to have some connection 
with liver derangement. Diarrhoea and vomiting are present in this form, 
and occur very early. The vomiting is " bilious" in character, and icterus 
is generally more or less strongly marked. Somnolence and stupor like- 
wise may occur in this form, which is an extremely unfavorable symptom. 

Another variety, which is peculiar to old age, is remittent pneumonia. 
All the symptoms, after energetic treatment, cease for a time — to return, 
however, with greater severity the next day ; and as this lull in the disease 
seems most promising, a prognosis might be given which would suffer em- 
barrassing contradiction in the future developments of the case. 

Physical signs. — Before the physical signs of senile jmeumonia can be 
accurately estimated — if, indeed, this is possible, the physiological modifica- 
tions of old age must be carefully considered. 

Eespiration, as has been said, is mainly diaphragmatic in old age ; the 
average number per minute is from twenty-one to twenty-two, and inspira- 
tion is to expiration as six to nine. 

The physical signs are modified by the bony union of the different 
parts of the sternum and ribs, by curvature of the spine that is generally 
well marked in old age, by the rigidity of the bronchial tubes, by the 
rounded form of the chest in advanced life, and, finally and most impor- 
tant of all, by that rarefaction of the lungs to which reference has been made. 

Percussion. — From the above-mentioned considerations, one would ex- 
pect, what actually occurs — a very clear percussion-note, and occasionally 
one that, compared with an adult chest, is abnormally resonant. 

When the air-cells have ruptured to any considerable extent, you may 
elicit, on firm percussion, a resonance as well marked as occurs in slight 
adult emphysema (the reverse of what occurs in middle life); the clavicular 
region near the median line gives a dull percussion-sound on account 
of the great arching of the sternum and the great deposition of carbona- 
ceous material at the apex of the lungs. 



204 CLINICAL LECTURES ON 

The infra-clavicular and mammary regions are extra-resonant. 

The lungs being pushed back to the spinal column, the sternal region 
is less resonant, and may often sound almost dull ; the heart-liinits can be 
accurately marked out, on account of its being uncovered by lung-tissue. 

The scapular and supra-scapular spaces are less resonant than in the 
adult, on account of the tilting of the scapulae, due to curvature of the 
spine. 

Auscultation. — There is a loss in the vesicular element of the respiratory 
murmur in old age. The respiratory sound resembles closely that pro- 
duced by a rather forceful expulsion of air from the compressed lips, and 
is diffuse in character, sounding as if the incoming column of air met a 
thinned and readily vibrating membrane ; the murmur is louder and less 
soft than in adult life. 

In lungs where the septa are torn and the alveoli greatly distended and 
irregular, the respiratory sound is bronchial in character. 

The intensity of the respiratory murmur in old age is variable : at one 
moment it is loud, at another, hardly perceptible ; and it varies not only 
thus in the same individual, but also in different individuals of the same 
age and condition of body. 

The voice-sounds are very loud ; occasionally there is even bronchophony, 
and in very extensively atrophied lungs this bronchophony has a vibrating 
or catching character, causing it to resemble very closely cegophony. 

Finally, it is an almost -physiological condition for old people to have a 
bronchorrhcea ; hence, mucous rales may be constantly present during the 
whole period of advanced life. 

To the physical signs of pneumonia one always turns for confirmation 
of his diagnosis, but here one will be misled who has in mind only the 
usual adult signs. 

Fikst Stage. — Inspection and palpation in the first stage of senile pneu- 
monia furnish little positive information. 

Percussion may reveal slight dulness ; this is very rarely the case until 
the lung has reached the stage of red hepatization, and even then it may be 
so slight in character as to leave grave doubts of its existence. 

Auscultation. — Very early in the disease the respiratory murmur is feeble 
and indistinct over the affected portion while the lung that is not involved 
assumes for the time all the characters of a normal adult respiratory mur- 
mur. 

Again, the breathing over the pneumonic spot may be intense' 
and in such a case will usually be rough, interrupted, or broken in char- 
acter. 

Tubular breathing may sometimes be heard at the root of the lung, and 
then the respirations are generally markedly feeble. 

A peculiar bronchial souffle is often heard over the inflamed lung, and 
in some cases this is audible in the superior sternal region. 

As soon as the pneumonic exudation occurs in the adult, the distinctive 
crepitant rale is heard, but in advanced life a distinct crepitant rale in the 
first stage of pneumonia is rarely present 

But subcrepitant rales, and large, moist rales, resembling to BOOM 
tent what we hear in capillary bronchitis, but oftener analogous to the 
rales of a simple bronchitis, are heard during the period of exudation. 

The reason for the almost invariable absence of the crepitant i 
seems to me. to be found in the physiological condition in old age ; the 
alveoli are dilated, their walls are thinned and frequently perforated, and 
the lungs themselves are retracted from the chest-wall. 



THE DISEASES OF OLD AGE. 205 

Sometimes, when you make the patient cough violently for a few min- 
utes, and then have him take a deep inspiration, you may hear fine crepita- 
tion ; but, upon closer examination, it will still be found to be subcrepitant 
in character, in no wise differing from that of capillary bronchitis." 

Soon the crepitation, whatever character it may assume, extends over 
the chest, from the general bronchitis that so soon accompanies the dis- 
ease, and masks, in whole or part, the respiratory sounds. 

It may be stated, as a general rule, that the feebler and more superficial 
the respirations, the less distinct will be any adventitious sounds. 

The dilation and rigidity of the bronchi that are physiological in old 
age, of course favor the development of bronchial breathing, which, indeed, 
is oftentimes the first physical sign of the pneumonia. One of its peculi- 
arities, when occurring in the stage of engorgement, is that it is limited to 
the root of the inflamed lung. 

Hence, this is an important sign, and one that should be always listened 
for in all doubtful cases. In the unaffected lung the breathing is often 
puerile, and sometimes accompanied by dry, transitory bronchial rales ; 
and in a few exceptional cases, when the lower lobes are involved, the 
upper give evidences of hyperemia. 

Adjacent to the inflamed portion the respiratory murmur is very much 
weakened. 

Second Stage. — Inspection in some cases reveals diminution in the ex- 
pansibility of the affected side, but this is not constant. 

Palpation may or may not show increase in the vocal fremitus. 

Percussion. — What is dull in old age might be regarded clear in the 
adult ; hence, when dulness on percussion is said to mark the stage of con- 
solidation, the term is only relatively true. Still, when superficial, there 
may be actual as well as relative dulness. The dulness is best marked 
posteriorly. 

Auscultation. — Tubular or bronchial breathing marks the second stage 
of senile pneumonia, and the sounds are even more intense than in adult 
life ; small gurgles or mucous rales generally persist throughout this 
stage. Bronchophony is not very well marked, even when present ; while 
segophony, from the quavering voice in advanced life, is far from infre- 
quent. 

Third Stage. — Inspection gives negative results. 

Palpation may or may not reveal increase in the vocal fremitus, accord- 
ing as it was present or absent in the previous stage ; but in general 
vocal fremitus decreases. 

Percussion shows the dulness to be decreasing — the chest again becoming 
very resonant. 

Auscultation shows the crepitating sounds to be louder ; and the gurgles 
loud and large, often heard at a distance from the pneumonia. 

The rdles redux, then, are not, as such, distinctive of, or peculiar to the 
third stage of senile pneumonia. The sound heard at this period of the 
disease is called a muco-crepitating sound, by which is meant a form of sub- 
crepitant rale produced in tubes intermediate between the bronchioles and 
the larger bronchi. 

Finally, as has been hinted, the physical signs of pulmonary abscess in 
the aged are very generally wanting ; distinctly localized gurgling and 
cavernous respiration may, when taken in connection with the rational 
signs, suffice for an approximate diagnosis, but the great rarity of abscess 
in old age should make us cautious in its diagnosis. The sputa will greatly 
aid us in such a case. 



206 CLINICAL LECTURES OS 

The physical signs of senile pneumonia are subject to greater variations 
than ever occur in pneumonia in the adult ; and often they do not even 
follow the course, irregular as it is, that I have just described. 

Gray hepatization, or abscess, may be reached without any distinctive 
auscultatory signs being heard, even on repeated and careful examination. 

Even in "resolution " the rale redux may be absent ; dulness and bron- 
chial breathing being immediately followed by normal (senile) resonance, 
without crejiatation. This occurs most frequently in the M typhoid " 
variety. 

Differential diagnosis. — The question very naturally 
senile pneumonia be diagnosed if it may run M without either 

expectoration or physical signs, the symptoms on which we so implicitly 
rely for a diagnosis of pneumonia in adult life ? 

Grisolle says that an exploration of the thoracic organs in pneumonia 
of the aged gives negative results in a majority of cases, and that we n 
base our opinion, 1st, on the extreme frequency of pneumoni . .ge ; 

2d, that, of all the phlegmasia of advanced life, pueumou. one 

which is oftenest latent ; 3d, that, of all acute diseases in ol 
monia produces the high* 
tration. 

So, when an old person has a chill, followed by febrile movement and 
great prostration, and when the superficial ami splanchnic portions of the 
economy (other than thoracic) do not account for it • be 

diagnosed, even though all its (adult) diftgno 

A few practical hints as to the means of diagm their 

place here. 

The characteristic ex] e obtained on violent couu 

after several swallows of fluid have been taken. 

On causing the patient to cough and expire violently, 
tion, and tubular breathing 

"When there is no cough, rep 
it and dyspnoea also. 

Senile pneumonia may be confounded with capillary : and 

pleurisy. 

In both capillary bronchitis and senile pnenmoni - amuco- 

itant or subcrepitant rale ; but in pneumoi.. eumseribed to a - 

three or four inches in diameter, while in capillary bcond 
and heard best over th< 

When both lungs are i in pneumonia, 

while they are simultaneous in capillary bronchitis. 

There is dulness, or at least a diminution • sonance in pneu- 

monia, whereas an exaggerate 
bronchitis. 

In pneumonia there may be bronchial breathing, wliile in C 
bronchitis the vesicular murmur is feeble — often al 

In pneumonia there is but one, the initiatory chill, while in capillary bron- 
chitis there are several slight attacks of chilliness daring The 
pulse in capillary bronchitis may run op to 140 or 150 in the ear 
while 120 is about the limit of the pneumonic pall 

The temperature is always higher in ueumonia than in capillary 

bronchitis. Cyanosis is a marked and mptom of capillary bron- 

chitis, while it occurs only late in pneumoni.. erunner 

of death. 

Finally, a microscopic examination of t : -will 



THE DISEASES OF OLD AGE. 207 

decide as to the condition of the alveoli, and whether pneumonia is or is not 
jjresent. 

A pleurisy with effusion sufficiently extensive to cause dulness would 
cause bulging of the intercostal spaces, with more or less displacement of the 
heart or liver, whereas these never occur in pneumonia. 

Again, the percussion-note would be flat over a large extent of sur- 
face in pleurisy, while a pneumonic spot would be evidenced by localized 
dulness over a small extent of surface. Besides, the line of flatness changes 
with the position of the patient in pleurisy, and is, of course, always sta- 
tionary in pneumonia. 

There is usually absence of vocal fremitus in pleurisy, while in pneumonia 
it may be increased, or at least normal. 

The respirations are " catching " in pleurisy, and panting in pneumonia. 

If bronchial breathing exist with a pleurisy, it is not as sharp, denned, 
and tubular in character as iu pneumonia, but rather subdued and diffused. 
Increased voice-sounds, bronchophony and cegophony are present in pneu- 
monia, while the voice-sounds are feeble over the pleurisy. 

A chill, when it introduces a pleurisy, is very slight, often absent ; a pa- 
tient with pneumonia generally gives a history of a distinct, often a severe 
chill. 

The temperature in pleurisy is two, three, or more degrees lower than 
in pneumonia. 

The face is flushed in pneumonia, while in pleurisy it is pale and anxious. 

The pain in pleurisy is sharp and stitch-like in character, located at the 
nipple of the affected side, while in pneumonia it is often absent, and when 
present is dull, diffused, and referred to various remote regions, all of 
which have been mentioned. 

It may be added here that the diagnosis of a pleuro-pneumonia is made 
upon a combination of the chief signs of senile pleurisy and pneumonia. 

Prognosis. — This is always grave, and the greater the age of the patient 
the less are the probabilities of recovery. 

Statistics do not give pneumonia its proper place among fatal diseases 
of old age. I believe it to be the most fatal of all the acute diseases at 
this period of life, for the number of autopsies that have been made in cases 
of "sudden death," in individuals of advanced years who have had "low" 
fever, "nervous" fevers, etc., exhibit in the vast majority of cases rector 
gray hepatization (of greater or lesser extent) that was not suspected during 
life. Many of the most reliable modem authorities — those who have had 
the largest experience in the hospital practice of the aged — state that nearly 
nine-tenths of those over sixty-live die of pneumonia. 

When pneumonia is single and confined to the lower lobes, the prog- 
nosis is much better than when it has its seat at the apices of the lungs. 

The prognosis is also more favorable when delirium is absent and the 
pulse is not irregular or intermittent. When the pulse-rate does not ex- 
ceed 110 or 120, and when the temperature-range is not above 103°, the 
prognosis is favorable. Thick, creamy sputa are very favorable signs. 

Prune-juice expectoration, the presence of any complication, extreme 
dyspnoea, excessive prostration, a sallow face, all these are very unfavorable 
signs. 

It is difficult to establish the average duration, but, in general, a prim- 
ary adynamic pneumonia lasts from six to ten days ; in fatal cases the sev- 
enth day is rarely passed. 

The first stage rapidly passes into the second, perhaps m four or six 
hours. 



208 CLLNICAL LECTURES OX 

The stage of purulent infiltration, if it occurs, is reached very frequently 
before the third day, and in some instances within thirty-six or forty-eight 
hours from the onset. 

Pneumonia may be complicated by pulmonary oedema. Bright 
heart disease may have pre-existed, and thus act as complication 
results from cardiac failure, from asthenia, or from coniplicatio: 

Treatment. — The therapeutics of pneumonia in advanced life is very dif- 
ferent from that of adult life : often the third stage is reached before the 
aged patient consults you. 

Never bleed in senile pneumonia. 

In the Salpetriere it seems that an emetic, when not especially co 
indicated, was usually given in the fir <>nia. 

Tartar emetic is never 1 pneumonia. 

The physicians of the Mbntpelier General Ho spi t al regard ipeoacn 
as an heroic remedy in senile pneumi 

English physician & potash as efficacious : 

mans prefer hydrocblorate of ammoi 

Drastic pur- 
ment of senile pneumonia. 

The most important tiling to sustain the L 

antipyretics are rarely D 

Alcoholic stimulants and concentrated fluid nui 
liances in the treatment of this 
judicious use of stimulants arc all that are required ID t 

Iron and quinine may be employed in mod - the 

sustaining plan of treatment 

In typhoid, asthenic pneumoni i of q^uinu e ad- 

ministered with benefit; and the diarrhoea occurring with typhoid pneu- 
monia must be promptly checked by 



THE DISEASES OF OLD AGE. 209 



LECTUKE XXIV. 

SENILE CHRONIC CATARRH OF THE BRONCHI. 

Summary. —Morbid Anatomy— Etiology— Symptoms— Differential Diagnosis— Prog- 
nosis — Treatment. 

Gentlemen :— Chronic bronchial catarrh is a very constant attendant 
of old age. It sometimes receives the name of " the old man's winter 
catarrh," one of its chief characteristics being its tendency to recurrence, 
the attacks increasing in severity and duration with each return of cold 
weather, until the individual is rarely free from it. 

It may be chronic from the onset, commg on late in life ; or it may be 
the sequela of acute attacks occurring in adult life or early manhood. 

Morbid anatomy. — Senile bronchial catarrh may have its seat in any por- 
tion of the bronchial tubes ; thus, it may be limited to the larger bronchi, 
or it may extend into the capillary tubes. Its anatomical changes are the 
same, whether it has its seat in the larger or smaller tubes. 

Usually the inflamed membrane has a gray or slaty blue color. 

The changes begin, primarily, in the mucous tissue, and subsequently 
involve the entire bronchial wall. 

Numerous small elevations and depressions are to be found upon it, 
often giving it a velvety look and feel. 

Occasionally it is of a deep brownish red color, and has a well-marked 
whitish look throughout the whole extent of the tract. Not infrequently 
the membrane is atrophied instead of hypertrophied, and it is then very 
thin, presenting neither fibrous nor cartilaginous tissue ; but, in either 
case the vessels are dilated — often tortuous. Vegetations, appearing as 
small, papillary elevations, may also occur. 

The bronchial glands are usually more or less enlarged, their mouths 
standing wide open and gaping. Two colored zones surround the gland, 
one around the centre, the other around the base. The process results in 
weakening of the walls, so that the violent and prolonged fits of coughing to 
which the individual is subjected cause dilatation at certain points. This 
dilatation, or bronchiectasis, is occasionally uniform — oftener, however, there 
is sacculation. The sacs, or ampullse, may attain the size of a hen's egg, 
and, when several are agglomerated, they resemble greatly a tuberculous 
excavation. The siu-rounding tissue always shows the characteristics of a 
jwi-bronchitis, all the changes being best marked at the periphery of the 
lung. Other portions of the tubes become narrowed, and so alternate 
stenosis and dilatation are very common conditions. 

The membrane may be covered with a thick, viscid layer of yellow, 
puriform material, or again (catarrh sec), a semi-transparent, glairy, mu- 
coid matter may cover, in a thin layer, the affected portions — the micro- 
scope revealing numerous pus-cells and columnar epithelium. 

The submucous coat exhibits an increase in connective tissue, and when 
14 



210 CLINICAL LECTUEES ON 

this increase involves the pulmonary parenchyma, we may have induration 
of the lung as the result. Just here it may be mentioned that the process 
resulting in fibrous induration may extend from without inward, i.e., from 
the pleura ; but it generally results from the inhalation of irritants, giving 
rise to a condition called "stone-cutter's phthisis." 

Accumulations of cheesy matter are occasionally found at points scat- 
tered irregularly throughout the bronchial tract, oftenest back of those 
localities where stenosis is marked. 

Again, degeneration, or decomposition of the secretions may result in 
ulceration, and thus a focus for gangrene of the lung is sometimes establ: 
The ulcers are usually tit the posterior portion of the t . rarely ex- 

tend deeper than the cellular tissue which connects the mucous membrane 
to the parts beneath. When, however, tb 
may occur into the oesophagus, I 

the pulmonary parent-]] Q abscesses 

may be excited by the perforation of a bronchial d the lun_ 

stance, or else inflammation ma] soli 

You very frequently find emphysema d< 
continued bronchitis, although under sue; 
will rarely be absenl ; and from wha: 
logical (senile) changes, it . 
most common pulmonary ] 

That ulceration which I with in • 

ease — the diffu-- Alicolar — may occur in though it is 

one of the rarest aocompanii irrh. 

The cartilaginous structures of the air-pass:. -jes sometimes suffer 
fication. In very old subje. I ns of ti. 

may become changed into os>« 
cavities of the bronchi — running through t" 
the bronchial cartilages ma\ brittle as to break 

or, during lite they may extend into the cavit iT, and 

be expectorated. Tubcr.lt ft] are Dot i' ssemi- 

nated throughout the lung ; such cases are more numerous the more ad- 
vanced th. 

Etiology. — Age is a n imposing cause of ehr< : 

chial catarrh. 

Vice of constitution LB 
under this head, stands g( nit, then rheum -eases, 

such as chronic i When the skin diaeaaei disappear, 

the bronchitis makes its appearance. 

Syphilis, chronic Bright 's disease, and chronic alcoholismus likewise 
predispose to this affection. 

Exposure to sudden changes of temperature — and thus a « •• 
climate, bad hygiene, overcrowding, poor ventilation, ai Q un- 

known atmospheric conditio:. c a o aea 

to bronchial catarrh. 

Organic diseases, such as reside in I 
mechanical and easily comprehended ma] 

the bronchial mucous membrane, and subsequently a state of d 
catarrh. 

Finally, it is to be remembered thai old persons exhibit a strong 

tendency to bronchial catarrh, even when the more marked p: 
and exciting eansi - lent 

Symptoms. — In the declining | 



THE DISEASES OE OLD AGE. 211 

than to find, during the winter months, a cough and expectoration which 
the patient avers he has had " on and off" for years. It may not materially 
interfere either with his general health, but it is nevertheless " trouble- 
some," generally abating or entirely disappearing in the spring and sum- 
mer months. 

A moist, cold atmosphere or unusual changes in diet aggravate it, and 
sudden exposure is very certain to bring about what may be called an 
acute attack, or what the individual calls a "spell." Going upstairs pain- 
fully increases the shortness of breath, and there is a general feeling of 
tightness or fulness across the chest. 

There are no febrile symptoms ; but more or less dyspnoea and wheez- 
ing are constantly present, the shortness of breath oftentimes simulating 
an asthmatic attack. 

The simplest form, the one in which the larger tubes alone are involved, 
is where a moderately severe fit of coughing, usually occurring in the 
morning, is followed or attended by the expectoration of a yellow, yellow- 
green, or grayish mucus, which soon after becomes white. 

In some cases it is glairy in character, and in nearly all a microscopic 
examination shows it to be made up of pus-cells and mucus, with, perhaps, 
9k few epithelial cells. 

The expectoration is oftenest nummular, although it occasionally runs 
together, and when very viscid is of an irregular, ragged, round shape, 
floating in a turbid, gray mucus. 

The name pttuitoua catarrh has been applied to chronic bronchitis 
when the sputum resembles the white of an egg mixed with water, and is 
ropy, clear, and gelatinous ; again, when with considerable coughing only 
a ball of pearl-gray, semi-transparent mucus is expectorated, it has been 
denominated "dry " catarrh — of course a misnomer. 

In this form the sputa are generally tasteless or slightly saline, or of a 
sickly sweetness and without odor. 

In the enfeebled and intemperate there is a form of chronic bronchitis 
where there is loss of flesh, and where night-sweats occasionally occur. This 
is marked by violent fits of coughing, followed by the expectoration of a 
gray, viscid, tenacious muco-purulent mass, which sometimes is watery, but 
which soon regains its muco-purulent character. 

The odor is sweetish, as a rule, but may often be slightly fetid ; it is 
never odorless. 

The amount varies ; but the average quantity is about a pint a day. 
During one of the paroxysms of coughing the effort to dislodge the mucus 
is often so strenuous that vomiting sets in, and the contents of the bronchi 
and stomach are ejected simultaneously. 

The expectoration contains, besides pus and mucus, epithelial cells in 
comparative abundance, albuminous matter, and now and then small por- 
tions of bronchial tissue. 

In this class of cases there is slight dilatation of the tubes and a small 
amount of attendant induration, but to a less extent than occurs in what 
Avill later be described as bronchorrhoea. 

Chronic bronchitis frequently occurs with gout, spasmodic asthma, and 
emphysema. (In the latter case the emphysema is the primary pathological 
condition.) 

In these cases the cough is violent, prolonged, and paroxysmal. For a 
time it seems as though the patient could not regain his breath ; his face 
becomes red, then livid ; the veins swell ; the eyes are suffused ; the head 
seems as if bursting, so that the patient clasps it in both hands ; the mouth 



212 CLINICAL LECTURES OX 

is opened in a sort of gasp ; the jugulars are swollen ; and vomiting is 
often the result of the diaphragmatic pressure ; finally, a small, rounded 
pearl of tenacious mucus is expectorated, the patient takes a deep breath, 
and though immensely relieved, is weakened by the " fit," and is exhausted 
for some time after. 

Bronchorrhcea, also called "pituitous flux" and "bronchial flux 
usually associated with heart disease, and is marked by violent fits of cough- 
ing — less intense, however, than in the last-named variety ; and the expec- 
toration, often a pint at a time, of a glairy, colorless, transparent mucus, 
with froth at the top, looks precisely like the white of an egg in WSJ 

Two or three pounds may be discharged in two hours ; some; 
large quantities are, as the patients say, vomited up of a mornii 
is, at times, the ejection of the fluid. I cases. 

This form, frequently accompanying cardi if very apt to 

cause grave symptoms when the patient is expoi ulden changes 

in temperature ; or, especially, to strong winds ; and it 
is liable to merge into, or be accompanied by, pulmonary i 

Extreme fetor of the sputa is generally aat 
excitement; and it may be ral rule. t<> which, 

there are many exceptions, that Cetid I i with 

bronchiectasis. 

The sputa arc dbundm lor, and. in ra 

in the form of the smaller tu 

Occasionally there ifl a slight blood-tinge i:i ti. 
indicates the existence of superficial ulceration : aometu 

tion becomes brownish and find, the iniCTOSi 
pus-globules mingled with Catty granules, crystals of 

(jar in. 

Mixed with water, the pus readily it lit- 

tle mucin is present : and the solid parts <»f I 

of the containing vessel, tl • 
whitish, cheesy plugs intermingled. 

Physical si<jn.<. — Inspection shows m<>r 
always aggravated by exercise, motion, i Somel 

chest presents a more concave shape thin normal. 

Palpatio)! may reveal an in 
and dilatation of the bronchial tub. - 

fremitus is local. If dilatation of the air-tul uiitus 

will be diminished. 

Percussion. — There is a loss in the palmed 
marked cases. 

When emphysema exists with bronchitis (and ti 
the percussion-note will be somewhat tympanitic in el. 

Auscultation. — Feeble respiration 
bronchitis in the aged. The variety of adventitious sounds heard di 
respiration is, perhaps, greater than in any other pulm -ease. 

The respiration is harsh in character, oft. 
cular quality, but not tubular ; it also lias a peeui. 

When the tubes are narrowed, and when 
pitched, hissing, and sibilant 1. couth: 

bronchi. 

A sonorous, cooing sound ha- In the larger tubes, where also 

are produced large gurgling sounds that result from the DUl 
bubbles. 



THE DISEASES OF OLD AGE. 213 

Similar conditions in the smaller bronchial tubes produce sibilant and 
subcrepitant rales. 

Since the bronchi of both lungs are affected at the same time, all varie- 
ties of dry and moist rales can be heard at different portions of the chest ; 
a sonorous is very near to a sibilant rale, and not far off is a subcrepitant 
or muco-crepitating rale. 

After a copious expectoration, the moist rales may wholly disappear for 
a time, and the auscultatory sounds vary greatly at different examina- 
tions. 

The sonorous and sibilant rales often completely mask the finer sounds. 
Fine sounds, like the musical notes from miniature organ -pipes, palpable to 
the patient himself, are frequently heard. 

When emphysema coexists, the expirations are prolonged and of a low 
pitch, and dyspnoea is much more marked. 

Bronchiectasis is evidenced at times by well-marked gurgling, the gur- 
gles being of large size, and most abundant at the lower portion of the 
lung. 

Finally, in long standing chronic bronchitis there will usually be some 
displacement of the heart downward, on account of the accompanying em- 
physema. 

Differential diagnosis. — Senile bronchitis is very often mistaken for senile 
phthisis. 

In phthisis there will be — when occurring with such symptoms as are 
common to chronic bronchitis — more or less retraction of the chest- walls ; 
while in bronchitis the chest is more frequently convex or bulging. 

Percussion in phthisis gives well-marked loss of resonance at the apex of 
the chest, which never occurs in bronchitis. 

Auscultation in phthisis may reveal a cog-wheeled or jerky respiratory 
murmur, a prolonged high-pitched expiratory sound, or the respiratory 
murmur may be completely tubular in character. 

These signs are not present in chronic bronchitis ; and if the expiration 
is prolonged, it is of low pitch. 

In advanced phthisis the dulness becomes wooden over the affected lung, 
there is amphoric or " cracked-pot " resonance on percussion, and on aus- 
cultation, cavernous or amphoric breathing with the metallic tinkle may be 
heard. 

These signs of a cavity are sometimes present in bronchiectasis, when it 
will be impossible to make a differential diagnosis ; in fact, such a form of 
chronic bronchitis may be regarded as bronchial phthisis. 

In all doubtful cases the history of the disease is important, and where 
the physical signs leave you in doubt, the presence or absence of fever, the 
character of the expectoration, and the amount of emaciation will decide the 
question. 

Prognosis.— Next to pneumonia, bronchitis is the most fatal disease of 
old age— some place it at the head of the list, but reasons have been given 
(see Etiology of Pneumonia) for questioning this statement. 

The duration of senile chronic bronchitis varies very greatly ; there are 
many cases where the old man's winter-cough has existed for twenty years. 
It may be relieved, but not cured ; the elements that oppose or favor re- 
covery are the following. 

The older the patient, the longer he has had the disease, the more 
feeble his condition, the more marked the predisposition to bronchial 
affections, the less are his chances of permanent relief or of partial 
recover}'. 



214 CLINICAL LECTURES ON 

Again, a fetid expectoration, which is constant or increasing in amount, 
is an unfavorable sign ; as are also evidences of bronchiectasis or emphy- 
sema. 

Gout predisposes to acute attacks and gives permanency to the changes 
in the bronchial tubes. 

Emphysema and bronchiectasis predispose to pneumonia and pulmonary 
oedema. 

Hepatic congestion, abdominal dropsy and general anasarca are frequent 
attendants of chronic bronchitis ; seventy-five per cent, of such cases are com- 
plicated by a small, granular kidney. 

Intestinal catarrh is often a complication of chronic bronchitis, the chief 
signs being pain at the scrobiculus cordis, pain in the stomach, a sense of 
constant gnawing, a capricious appetite, indigestion, and flatulence. The 
liver is almost always simultaneously engorged in these cases. 

Death, in senile bronchitis, may result from pneumonia, gangrene, or 
oedema of the lungs, or from the renal, and rarely from the gastro-intestinal 
complications. 

Treatment. — A careful study of each individual case is important for the 
successful treatment of chronic bronchitis ; indiscriminate routine treat- 
ment, or the administration of favorite prescriptions, may do much more 
harm than good. 

A warm, dry climate, at a moderately high altitude, should be selected as 
a residence for this class of patients ; they should remain indoors as much 
as possible when the prevailing winds are east. Night air and cold are to 
be avoided. The sleeping-room should be well ventilated, and the temper- 
ature should be kept between 65° and 70 Fahr. 

Flannel should at all times be worn next the skin, and the cuta 
functions should be regularly stimulated by Turkish baths, rubbing, and 
moderate exercise. 

The diet must be simple and highly nutritious, for only in cases where 
the nutritive functions are active can any permanent relief be hoped for. 
The bowels must not be allowed to become constipated, and alcoholic stimu- 
lation must be regulated by the indications of each cae 

The most important thing to be accomplished initadtred treatment 
is the removal of its cause. 

When a weak heart is evidently its predisposing cause, digitalis may be 
administered. "When gout is prominent, colchicum, the iodide of potassium, 
and alkalies often produce marvellously beneficial efl\ im inhala- 

tions of hyoscyamus, coniuni, or stramonium are usually of great service in 
cases of gouty bronchitis. 

When syphilis is made out as the chief factor, iodide of potassium and 
the compound calomel pill will be found useful in connection with the 
iodine-spray inhalations. 

When there is amemia, which is very apt to be present in aged fen: 
cod-liver oil, iron, and moderate exercise in the open air, will be found of 
the greatest service ; while moderate stimulation, combined with qiiinine 
and strychnia, will sometimes give marked relief. 

When chronic skin discuses alternate with a bronchitu and sul- 

phate of zinc are to be administered for a long period. 

In emphysematous patients, iodide of potash, dilute nitric acid, and the 
ethereal extract of the acetate of iron, must be given daily for a long 
period. 

The rule m that a general tonic plan should be followed in all cases. 

In bronchorrho?a, and when the amount of secretion ipor 



THE DISEASES OF OLD AGE. 215 

inhalations of naphtha, creosote, balsams, copaiba, or ammonium chloride 
often have the effect of checking or diminishing it. 

When a severe attack of bronchorrhoea comes on, a hot-air or vapor 
bath may be given in connection with sedatives or stimulants, according to 
indications. Dry cupping may be occasionally employed in such cases with 
benefit. 

When there is evidently a lack of power to expectorate, ammoniacal 
preparations, squills, senega, and the resins frequently afford prompt re- 
lief. "When a large accumulation takes place in the bronchi, do not hesi- 
tate to administer an emetic of sulphate of zinc. 

When the cough is so constant and harassing that it interferes with 
sleep, opium and cannabis indica may be given for relief. 

Local treatment consists in the application of dry cups, sinapisms, blis- 
ters, or stimulating liniments to the chest. Croton-oil liniment is most 
frequently used. Any of these measures may be employed, when they have 
been found to afford relief. Bloodletting is always contraindicated. 

Hepatic and gastric complications are best relieved by an occasional 
mercurial purge. 



216 CLINICAL LECTURES ON 



LECTURE XXV. 

ASTHMA. 

Summary. — Nature — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treat- 
ment. 

Gentlemen : — Asthma stands next to bronchitis in the list of trouble- 
some affections of the respiratory apparatus in old age. 

It is now regarded as a disease of purely nervous origin. It has no 
special morbid anatomy. 

Tonic muscular spasm, or contraction of the circular muscular fibres of 
the bronchial tubes, is the essential element of an asthmatic paroxysm ; and 
their consequent narrowing, as evidenced by unmistakable physical signs, is 
a mechanical result. An analogue of this is found in spasmodic stricture 
after a gonorrhoea ; for a bronchitis is known to be the exciting cause in 
many cases of asthma. The bronchial membrane is first vascular, then 
occur certain catarrhal processes with which you are acquainted, and sub- 
sequently, through reflex nervous irritation, there is spasm of the bronchi, 
which is asthma. 

Etiology. — The causes may be divided, for convenience, into primary 
and secondary ; meaning thereby that one class affects directly the air-tubes, 
the other some organ or part remote from the respiratory apparatus. 

When the asthmatic tendency is present, there are a multitude of arti- 
cles which cause its development, such as smoke, dust, a fog, emanations 
from stables, hay, roses, burning sulphur matches, sealing-wax, the odor of 
horses, cats, and other animals — any of these may be sufficient to bring 
on a paroxysm of asthma. 

In some a neighborhood where filth prevails is one where their asthma 
is best, in others the approach to such a place brings on an attack. 

The same is true of dry air and moist air, of high lands and low lands, 
the mountain and the seashore. Some asthmatics cannot sleep or be free 
from asthma except in certain parts of the house ; and. again, the na- 
tive place of some patients is the only spot where they enjoy immunity 
from the disease, while others can never be free from it at home. These 
idiosyncrasies are strongest in advanced life, and are by no means im- 
aginary ; for, to witness the suffering of certain old persons when they dis- 
regard their well-known individual idiosyneracies, will be enough to show 
how real all these causes are, and at the same time show how powerfr. 
vous influences are in producing asthmatic paroxysms. 

Asthmatic attacks may be excited by the ingestion of certain artie: 
food ; this is the "peptic " asthma of some authors. The peripheral pneu- 
mogastric filaments in the stomach's wall probably suffer irritation in 
cases, and thus secondarily induce sp-sin in the parts supplied by tin 
ramifications of this nerve. 



THE DISEASES OE OLD AGE. 217 

Broucliial catarrh is probably the most frequent of all the secondary 
causes of asthma in the aged. The tendency to asthma is often latent un- 
til a general bronchial catarrh is developed. Heart disease, "cardiac" 
asthma is the least common of all. It is produced in the vast majority of 
cases in a purely mechanical manner : by causing a passive hyperemia of 
the bronchial mucous membrane. 

The retrocession of gout and rheumatism, the abrupt disappearance of 
chronic eruptions upon the skin, the stoppage of an habitual discharge — 
any of these may be followed by a paroxysm of asthma, and it may be from 
the latter cause that the drying up of old ulcers is capable of producing 
the malady. Sometimes aged asthmatics have applied at the hospital for 
irritating dressings to keep open old ulcers, so certain were they of the 
effects of their healing. 

Among comparatively rare causes are cold feet, a loaded rectum, an en- 
larged prostate gland, and organic diseases of the brain. 

Finally, there is sometimes a well-marked hereditary predisposition, 
and, again, no cause can be discovered to satisfactorily account for the asth- 
matic paroxysms. 

Synijrfoms. — The symptoms of asthma may be divided into those which 
are present during the attack and those of the interval. 

Prodromal symptoms are of rare occurrence in the aged ; but when 
they are present they consist of languor, drowsiness, and depression, or 
the opposite condition of extreme lightness of spirits. There is very fre- 
quently a large quantity of " hysterical " urine passed some hours before 
the attack ; indeed, all the prodromata of asthma are eminently nervous in 
character. 

The attack proper — whether premonitory symptoms have or have not 
preceded it — usually begins with a sense of constriction across the chest, 
aud the peculiar paroxysmal dyspnoea. When, as is common in old age, 
dyspnoea is habitual, there is a sense of suffocation, and the patient begins 
to wheeze, cough, and perhaps has a fit of sneezing attended by running 
at the nose. 

There are anorexia and flatulent distention of the abdomen, with 
wheezing and increasing d}'spncea ; these may continue for a day or 
more. 

Again, there are no warning symptoms at all, and the attack comes on 
suddenly and unexpectedly. 

Early morning — from two to four o'clock — is the usual time for an 
asthmatic to be waked out of sleep by difficulties of breathing. Dyspnoea 
increases and becomes suddenly or gradually intense, so much so that it 
seems sometimes as if the patient could not live ; every muscle is called 
into play that aids in enlarging the chest, and all possible positions are as- 
sumed. 

The aged patient rushes to and opens the window to get air. 

The shoulders are elevated and brought forward. 

The face is pale or dusky, the features are altered, the mouth is wide 
open, the nostrils dilated, the veins in the neck and forehead are turgid, 
and the sufferer feels as if death were impending. 

Though he is in a dripping perspiration, the extremities — the lower 
especially — are cold ; the pulse is small, rapid, and thready. 

If expectoration have existed, it ceases in the acme of the paroxysm, 
and not until this is resumed will the fit end, not because the voiding of the 
collected mucus relieves the paroxysm, but because, when the bronchial 
spasm passes off, expectoration follows. 



218 CLINICAL LECTURES ON 

Even when the attack begins " dry " there is always expectoration at 
the end, the result (not the cause) of the spasm. 

True asthmatic sputa consist of grayish pearls of mucus, like tapioca, 
and are usually free from either pus or watery material. 

So intense may be the paroxysm that streaks of blood appear in the 
sputa ; and in some (rare) cases, this amounts to actual hemorrhage. 

There is no rule as to the duration of one of these paroxysms. They 
sometimes continue for half an hour. I have known a paroxysm of asthma 
to continue for seventy-two hours in an old man of eighty. 

Less violent attacks may continue without remission for five or six 
days ; again, each attack is made up of several shorter ones, the intensity of 
which varies greatly in different cases. 

The longer the attacks the slower and less abrupt the departure, and the 
more profuse the sputa. 

After an attack the patient is often reduced in strength and exhausted, 
has aching limbs, depression of spirits, and a feeling of " soreness" in all 
the respiratory muscles. 

In " cardiac " asthma, the symptoms are very much aggravated, and the 
patient being usually conscious of the heart-lesion, has not even hope left 
in the midst of his sufferings, and often prays for death to come and end 
them ; after an attack of this kind, convalescence is very slow. 

The character of different attacks in the same individual varies. If at 
first they are violent and exhausting, later they may assume a milder form, 
and lose somewhat their periodical character and run into each other, so 
that the individual is never entirely free from paroxysmal dyspnoea. 

There is always at first a periodicity to asthmatic attacks, the intc a 
between the paroxysms varying in length. 

As a rule, the longer the individual has been subject to asthma the 
shorter the interval between the attacks ; this is especially true in the verv 
old. 

It may be mentioned here that no physical signs are present, except 
during the paroxysm. 

Some have stated that the urine exhibits a remarkable diminution in 
chloride of sodium and urea immediately after an attack, while later 
resume their normal standard. 

Usually, after an asthmatic attack has passed, most asthmatics are com- 
paratively well ; the patient feels certain he will be free, for a certain time 
at least, from another, and mean while can enjoy good health. 

Physical si</>>s. — During the paroxj shows labored breath- 

ing, but no increase in the number of the respirations. Inspiration is 
shortened, while expiration, though effected by abrupt and violent efforts, 
is longer than normal. The muscles of the neck are immovable and the 
vessels are distended. 

Palpation gives normal vocal fremitus. 

Peivussion elicits slightly exaggerated resonance. 

It is auscultatio)} that enables us, if doubt could exist in well-niarked 
asthma, to obtain distinctive results. The inspiratory murmur is heard 
very faintly or is wholly absent ; this is especially the case in very old sub- 
jects. No vesicular quality is present, and the expiration-sound i- 
longed and low-pitched. 

Sibilant and sonorous rales, high-pitched, hissing, wheezing and squeak- 
ing in character, are heard over the whole chest, and especially over and 
between the scapula? in the very old. 

Often these dry sounds have a musical character. When moist sounds 



THE DISEASES OF OLD AGE. 219 

are heard, it is either because chronic bronchitis complicates the asthma, or, 
as the paroxysm is drawing to its close, mucus collects in the tubes. Asth- 
matic sounds are oftentimes heard at some distance away from the sufferer. 

The number and kind of sounds heard during the beginning of a 
severe asthmatic attack cannot be enumerated ; they are constantly chang- 
ing their locality, and also their nature in the same locality. 

In some cases— the tubes perhaps not being all affected, or equally so — 
the respiratory murmur is heard in patches ; it is apt to be exaggerated in 
these spots. 

All the sounds are loudest during expiration, and in some instances 
they may even be limited to that period. During the interval between the 
paroxysms there are no abnormal sounds. 

Differential Diagnosis. — Asthma may be confounded with laryngeal 
.spasm, angina pectoris, pulmonary cedema, bronchitis, emphysema, and 
pericarditis with effusion. 

I. — Spasm of the glottis is attended with voice-changes never present 
in asthma ; and, besides, there are the physical signs of asthma. 

II. — Angina pectoris is attended by pain of a lancinating, cutting, or 
stabbing character, while asthma is, as its name indicates, a gasping for 
breath. Angina pectoris is accompanied by no physical signs of pulmonary 
abnormalities, while the patient himself usually attributes everything to 
the heart. 

III. — In pulmonary oedema there is dulness on percussion over the 
oadema, while in asthma the chest is extra-resonant. 

The rales in cedema are liquid bubbling rales, while asthmatic sounds 
are dry. 

Pulmonary oedema is early accompanied by profuse watery expectora- 
tion, while after an asthmatic fit small pearls of gray mucus may be expec- 
torated. 

TV. — Bronchitis is of slower advent than asthma, and is accompanied by 
the distinctive moist redes, while asthma is marked by manj r and various 
dry sounds, and is very sudden in its advent. 

The respirations in bronchitis are always more rapid than in asthma. 
The character of the sputa will also aid in the diagnosis, for it is usually 
purulent in the former, and never so in asthma. 

V. — Emphysema is never wholly unaccompanied by dyspnoea, while 
asthmatic patients do enjoy intervals of immunity. 

Emphysema is accompanied by its characteristic percussion-note, vesi- 
culotympanitic in character, and this is never present in uncomplicated 
asthma. 

Prolonged low-pitched expirations exist, usually in emphysema ; and in 
asthma, the duration, if prolonged, is never low-pitched. 

Finally, the aspect of the patient, the barrel-chest, and the change in 
the position of the heart which accompanies emphysema, will enable you 
to make a diagnosis. 

VI. — Perhaps one of the diseases most likely to be mistaken for asthma 
when it occurs in old age, is latent pericarditis with effusion. It may be, 
and often is, accompanied by dyspnoea, which is spasmodic in character, 
and pain may be wholly absent ; hence the mistake in the diagnosis. 

The chief signs by which pericarditis is to be recognized, are feebleness 
and often irregularity of the pulse, faintness, diminished cardiac impulse, 
obscure heart-sounds and increase in the precordial dulness ; and, nega- 
tively, in pericarditis there will be no rales, no history of previous asth- 
matic attack — indeed, no pulmonary symptoms whatever. 



220 CLINICAL LECTUEES ON 

Prognosis. — Senile asthmatics are generally long-lived ; a paroxysm of 
asthma rarely terminates fatally, and when death occurs during an attack, 
it is most generally from pulmonary oedema or congestion. 

It is the attendant circumstances that have to do with the establishing 
our prognosis ; and also the fact that severe and prolonged attacks may 
bring on emphysema of the lungs and right cardiac hypertrophy., and dila- 
tation incident to obstruction in the pulmonary capillaries during these 
paroxysms. 

When organic diseases exist, as for example, a chronic bronchitis, then the 
disease must be looked upon as incurable ; and the more advanced the age, 
the more unfavorable is the prognosis ; hence, in this class of patients the 
disease may be put down as inc. arable. 

"When no abnormal lung- or heart-sounds are heard during the intervals 
between the attacks, the outlook is better than when the reverse is the 
case. 

Asthma may be complicated by cln*onic bronchitis, emphysema, bron- 
chiectasis, pulmonary oedema and congestion, cardiac dilatation and hyper- 
trophy. 

Death, if it occurs, usually results from the pulmonary complica- 
tions. 

Treatment. — In the treatment of asthma, two things are to be consid- 
ered : how we may relieve the paroxysms, and how we may prevent their 
recurrence. In other words, the treatment is to be palliative rather than 
curative. 

"When a patient has a paroxysm of asthma, the first thing to be doi 
to remove the exciting cause when it can be reached. When the st< 
has been overloaded, an emetic should be given ; when the rectum is over- 
filled, an enema should be administered : when smoke, dust, or the emana- 
tion from anything which induces the tit. these should be removed, or the 
patient withdrawn immediately from their influence. It is the same with 
localities and emotions, or nervous impressions. 

The removal of the cause may alone bring about speedy relief. But 
when this is not the c~z% or when no ca le, then certain 

remedial measures may be employed. 

The room in which this class of invalids spend most of their time should 
be large and well-ventilated, the curtains should be removed, and all ob- 
struction to the ingress oi sunlight and fresh, cool sir The 
idiosyncrasies of old people suffering (hit should 1 

The next step is to select those remedies best adapted to the esse, and 
the choice depends much upon the individual's experience and individual 
constitutional idiosyncrasies; most asthmatic patients know what Lb 
suited to their case. 

The remedies may be divided into three classes : depretmnt*, wedai 
and stimulants. 

1. Depressants, — The chief drugs in this class are antimony, ipe 
anha, lobelia, and tobacco. The object in the use of these is to com} 
relax the spasm, and whichever drug is chosen it should be exhibited until 
the required effect is produced. 

Ipecacuanha may be given to produce nausea, and tobacco should be 
smoked until nausea and a feeling of faintness come on, when the attack oi 
asthma ceases. Mild tobacco should be used by old people and vomiting 
ought never to be induced by its use. 

2. Sedatives act either locally on the pulmonary nervous apparatuf 
generally upon the whole nervous system. 



THE DISEASES OF OLD AGE. 221 

Those of the greatest value in asthma are chloroform, opium, stramo- 
nium, ether, cannabis indica, hyoscyamus, and the fumes of nitre-paper. 

There is, perhaps, no agent that so promptly relieves as chloroform, and 
this, too, when all others have failed. Great care should be exercised in 
giving chloroform to the aged, and the condition of the heart must always 
be carefully considered. The relief is in any case but temporary. 

Ether is pleasanter than chloroform, both to inhale and in its results : a 
combination of the two will in some cases be fourd more effective than 
either alone. 

Hypodermics of morphia, when combined with atropine, act well in many 
cases ; this combination acts much more powerfully than either drug alone. 

Nitre-paper, one of the oldest and best known remedies for asthma, is 
prepared by dipping filter- or blotting-paper in a saturated solution of salt- 
petre. The fumes of the nitre-paper give no relief when bronchitis ac- 
companies the asthma, and as these two maladies coexist so often in old 
age, it is seldom of much service in senile asthma. 

When used, the room must be filled with the fumes from the burning- 
paper. Its action is not well understood. 

Stramonium leaves, when smoked, will in some bring about speedy re- 
lief, while in others no relief follows their use. Internally, in the form of 
extract, stramonium does not afford the same relief as when the dried leaves 
are smoked. The datura tat via is regarded by some as more efficacious 
than datura stramonium. Many old asthmatics will not go to bed until 
they have "had their stramonium pipe." 

It may be added here that the habitual use — in either sex — of tobacco 
seems to have a favorable influence, and in some cases gives complete relief. 

Conium, hyoscyamus, and belladonna sometimes afford relief, but much 
less certainly than the stramonium. They may be tried, however, in obsti- 
nate cases. 

The nitrite of amyl has not proved as successful as its physiological prop- 
erties would warrant us to expect. 

3. Stimulants. — The two chief stimulants to be employed in the treatment 
of asthma are coffee and alcohol ; coffee is the most efficient, and should be 
taken upon the occurrence of the first symptoms of an asthmatic attack. 
It must be very strong and without milk. Two or three cups are sometimes 
necessary to ward off an attack. It should never be administered on a full 
stomach, for then it may excite or aid in inducing an attack. 

Alcohol is sometimes of great service in the treatment of asthma. It is 
of little importance what form of alcohol is employed, provided it is hot 
and strong ; in other words, it must be given as a " hot toddy." It must be 
given in sufficiently large doses to produce its intoxicating effects. As it is 
sometimes the only remedy that will relieve, and as larger doses are re- 
quired at each attack, there is danger that its use may become habitual. 

Asthmatic patients who are relieved by alcohol, as a general rule, have 
their paroxysms occurring during sleep, and as during sleep the nervous 
system is more depressed than during waking hours, these individuals are 
more susceptible to the exciting causes of the asthmatic fit when asleep 
than when awake. 

As in all nervous conditions the remedy which is first "the specific," so 
called, will later become useless, and then a new one must be tried, and so 
the changes may be rung on half a dozen drugs with success. 

Compressed air has not been found serviceable in the treatment of 
asthmatic attacks, and the inhalation of oxygen does not exercise any mark- 
edly beneficial influence. 



222 CLINICAL LECTURES ON 

The treatment in the interval is essentially hygienic, although some 
state that, in cases whose cause is undiscoverable, the iodide of potassium 
not only prevents or delays the attacks, but even prevents their return. 
Again, when cutaneous disorders appear to irregularly alternate with asthma, 
the internal use of arsenic will be found of service. 

Quinine, five or ten grains a day, will sometimes prevent asthmatic par- 
oxysms, and when old asthmatics suspend it for even a short time, the par- 
oxysms may return with greater severity. 

One, if not the most important duty of the physician in treating senile 
asthma, is the regulation of the diet of the patient. 

Breakfast, at eight o'clock, should consist of half a pint of green tea, or 
of coffee, and a little cream and two ounces of yesterday's bread. Dinner, 
at one o'clock, two ounces of fresh beef or mutton (no fat), and the same 
quantity of well-boiled rice or stale bread ; and in about three hours after 
dinner half a pint of weak brandy and water, and as much toast-water as 
desired. 

No water is to be taken within one hour before dinner or supper, or 
until three hours after. 

Flannel should constantly be worn next to the skin, and the flesh-brush 
may always be employed with benefit. 

Moderate exercise only is allowable, and cold bathing of the chest must 
be prescribed with caution in old people. Remember that old asthmatics 
are always prone to cold feet ; hence, woollen socks are to be worn, and all 
chilling of the body carefully avoided. 

When tonics are indicated, iron and quinine will be found best for 
asthmatics of advanced life ; as to climate, experience is here the only ami 
the best guide. 

It may be said that all confirmed asthmatics are dyspeptic. It is there- 
fore important to study the idiosyncrasies of each individual case, in the 
interval between the paroxya 



THE DISEASES OF OLD AGE. 223 



LECTUKE XXYI. 



ATHEROMA.— FATTY HEART. 



Summa ry. — Atheroma — Morbid Anatomy. 

Fatty Heart — Varieties — Morbid Anatomy — Etiology — Symptoms — Differential 
Diagnosis — Prognosis — Treatment. 

Gentlemen : — Before we commence the study of the diseases of the 
heart and blood-vessels in old age, I desire briefly to call your attention 
to the more important modifications which the heart and circulatory sys- 
tem undergo in advanced life. 

The heart of the aged differs in many respects from that of adult life. 
Contrary to what occurs in the other organs, it does not diminish in size 
or weight as age advances ; in very many cases it undergoes actual hyper- 
trophy. Indeed, it may be said to be physiological for the heart to exceed 
by one-twelfth its normal adult weight. 

Its average weight in males over sixty is eleven ounces — in females of 
the same age, nine and a half ounces. It is broader than in adult life, and 
the cardiac substance, in the majority of cases, is pigmented. 

Yet in emphysema, and in those very old people who seem " to shrivel 
up," the heart may be no larger than a base-ball, and somewhat resemble 
it in shape. 

The increased size and weight of the heart are due to progressive thick- 
ening of its walls ; the capacity of both the auricles and ventricles are in- 
creased ; and there is an enlargement of the auriculo-ventricular openings. 

The ratio of increase in the capacity of the right and left cavities is equal ; 
but the left ventricular walls increase in thickness much more than the 
right. This thickness of the left ventricle varies considerably with the 
place measured, since its thickness rapidly diminishes from base to apex ; 
at the latter point the endocardium and the tunica propria almost meet, so 
thin is the ventricular wall. 

The auriculo-ventricular orifices undergo a uniform enlargement ; but 
the aortic orifice enlarges much more rapidly and to a greater extent than 
the pulmonary, and some state that aortic insufficiency is physiological in 
old age. 

The valves are thickened, and so is the endocardium, either in points 
or throughout its entire extent. 

The ascending portion of the arch of the aorta is generally dilated to a 
considerable degree ; this is undoubtedly the result of the blood-current 
striking upon the aortic walls, whose elasticity is gradually diminishing. 
It may thus attain its double calibre, and the walls generally become much 
thicker in such cases. This thickening takes place in all the tunics of the 
artery. 

The loss in the elasticity of the aorta is due to connective-tissue in- 
crease and to fattv or to calcareous degeneration. 



224 CLIXICAL LECTURES ON 

Again, in many old subjects there is minute injection of tlie aorta and 
pulmonary artery just as they leave the heart. The reflected portion of 
the pericardium is then quite lax, as is also the subcellular tissue ; and the 
arteries and veins therein are enlarged and tqrtuous. 

The veins in old age lose much of their elasticity, and increase in size 
and in the thickness of their walls ; all venous changes are most marked 
in the lower half of the body. 

The amount of blood is diminished in old age (senile anaemia), and 
nearly all the viscera are in an anaemic condition. It contains less solid 
constituents, especially red globules and albumen. It is clearer, more fluid, 
contains more cholesterin, and coagulates much more readily than in adult 
life, which accounts for the coolness of the extremities in old age ; at least 
this is one of its causes. 

At this jDoint it is important that I should say a few words concerning 
atheroma, for this is the great factor in the production of all senile patho- 
logical changes. 

Atheroma. — The term atheroma includes a pathological condition of the 
arteries which may be, and often is, a combination of chronic arteritis, fatty 
and calcareous degeneration. 

The earliest stages of atheroma are marked by an infiltration of cells 
into and beneath the inner coat of the vessel. These cells are leucocytes 
mingled with connective-tissue cells. This hyperplasia causes bulging of 
the tunica intinia toward the axis of the tube. At first the swelling is soft, 
and can be easily removed. Retrograde metamorphosis gradually occurs 
as a result of defective nutrition, the new cells undergo fatty degeneration, 
and a soft, yellow mass, called an "atheromatous / tia," results; or, the 
lining membrane rupturing, the pultaceous contents are swept into the 
circulatory torrent, and we then have the atltcr 

Again, when neither of these processes occurs, the liquid portion of the 
mass becomes absorbed, cholesterin is formed, and then in the deeper 
layers there is a debris of broken-down cells, cholesterin crystals, fat- 
ules, and some of the original fibrillated tissue, which, subsequently 
fying, beeomes a calcareous plate. 

A frequent change in old age consists in thickening of the inner 

coats of the vessel 

In the aorta, just above the aortic valves, you will see, in old :. 
white or yellow-white patches extending over a considerable space. 

These calcareous plates are friable, transparent, and inelastic, sometimes 
thickened at their irregular rims, and when the vessel is dilated in - 
and the plates are numerous, we have what has been called "senile arteritis 
deformans," 

In old age the arteries of the brain and heart are affected in an ah 
equal degree, as well as those of the chief glands. 

The same processes and the saine results occur in old age in the 
valves of the heart, which are sometimes markedly cribriform and 
rugated. 

In connection with atJieroma may be described the whit- the 

heart and pericardium, which are unimportant, except that they 
common in advanced life, and are not found at other perio 

They are usually on the anterior surface of the right ventricle, and \ 
in size from that of a pin's head to that of a two-cent piece. Tin 
very irregular in shape, and sometimes can be dissected off if 
brane. There are two theories concerning them — an inflammatory I 
non-inflammatory ; the former is the 1 1 and support*. 



THE DISEASES OF OLD AGE. 225 

They occasionally occur on the pericardium, and are far more common in 
old men than women. 

The almost cartilaginous consistence which the vessels have, when 
atheroma is of long standing, may lead to sufficient retardation, or arrest, 
of the blood-current to cause arterial coagula ; and then gangrene of the 
extremities, fatty degeneration of the heart, or cerebral ramollissement 
may follow. This is sometimes called the "marasmic thrombosis," and 
there is, undoubtedly, a diminution in the influence exerted by the vaso- 
motor nerves upon the arteries. From this impediment may also come 
dilatation and tortuosity of the veins. 

In individuals in advanced life, it is rare not to find a chronic peri- 
arteritis accompanying the lesions of the heart and vessels which I have 
just described. And where the aortic arch gives origin to the great vas- 
cular trunks of the head and the upper extremit}-, rings of bone-like matter 
very often surround the orifice of the branch. 

Having considered the usual condition of the heart, vessels, and blood- 
mass in old age, and the lesions which constitute senile atheroma — that 
lesion which so often is followed by so many and terrible results — we are 
prepared to consider the modifications that occur in the heart and pulse in 
normal old age. 

Percussion. — The normal area of dulness in the adult, which, you re- 
member, is of a triangular shape, with the base immediately below the 
junction of the left third rib with the sternum, and the apex on a line of 
the cartilage of the sixth rib, is usually increased about half an inch in all 
directions in old age. 

The apex-beat is lower down, being, as a rule, three instead of two 
inches beneath the nipple, and is carried nearer the axillary line than in 
adult life. 

When the organ is overlapped by an adherent portion of the lung, or 
when there is emphysema, percussion may wholly fail to accurately map 
out the size of the heart, and to discover its exact dimensions. 

Auscultation. — As a rule, the heart-sounds may be said to be duller. The 
first sound, especially, seems in old age as if it were prolonged and muffled. 

A moderate aortic insufficiency is usually unaccompanied by any 
marked auscultatory symptom, but may give the same murmur and the 
same area of diffusion as in adult life. 

Pulsations in the veins. — It is stated by many writers that the tricuspid 
valves are normally in the aged slightly insufficient, and this is hence re- 
garded as a sort of safety-valve. Now, it has been said that the auriculo- 
ventricular orifices become larger in old age, and thus jugular pulsation, 
from both these causes combined, is a quite frequent occurrence iD old age. 
Now and then they are markedly distended, and you may notice a thrill. 

When aged subjects are excited, it is frequently the case that the veins 
above the clavicle present a marked undulatory movement, and this may 
be perceptible in the emaciated, even beyond the region of the neck. 

The pulse.— The heart's action in old age, although no less powerful than 
in adult life, is nevertheless accompanied by an impulse which is less 
visible. The number of pulsations in aged females is always greater than 
in males. As examples of extreme slowness of the pulse may be men- 
tioned the cases where the pulse in a man eighty-eight years old was 
twenty-nine, in a woman eighty-two, thirty-six ; and in a man eighty-nine, 
twenty. That such slow pulses are compatible with normal senile cardiac 
conditions, there can be no doubt. 

In old age, when no lesions are/ present, it is not uncommon for the 
15 



226 CLINICAL LECTURES ON 

heart to present irregularities both in the strength of its beats and in its 
rhythm. These two conditions may both occur in the same individual, or 
there may be only a loss of rhythm. 

It is a peculiar and interesting circumstance that when acute diseases 
occur in old people whose hearts are thus irregular, the rhythm and 
strength become, during the disease, perfectly normal, to change again 
when recovery occurs. There is no satisfactory explanation of this occur- 
rence. 

The pulse in advanced life is quite characteristic : it is, hard, wiry, and 
deficient in elasticity, so that its unvarying rigidity makes it an uncertain 
means of investigation. 

The radial artery shows the changes of age better than any other : as 
you slide the readily moving skin over the artery, the calcareous plates 
often give a sensation similar to that of passing the finger over a tube filled 
with shot. 

Failure to appreciate these arterial changes has undoubtedly led to 
many fatal bloodlettings in old age, for the older the subject the firmer 
and harder seems the arterial impulse. 

As I have already stated, it should always be the rule to count the pulse 
at the heart in old age. 

These are the more important changes in the heart and vessels in the 
aged. By keeping them constantly in mind, much of error may be avoided. 
The first cardiac disease that claims our attention is fattv heart. 



Fatty Heart. 

Fatty degeneration is the commonest degeneration in old age ; it is one 
of the prominent factors in what is denominated senile decay. 

Fatty degeneration may be either partial or general, and. as in adults, 
presents itself under two forma 

" Quoin's fatty heart " is a degeneration of the primitive muscular 
fibres, and is properly so denominated; while the deposit of fat in the 
areolar tissue of the heart, or the replacing of the connective tissue by fat, 
is in reality, fatty ii filtration. 

Morbid anatomy. — In advanced life, this degeneration is most often met 
with in the left ventricle near its apex ; next in order cornea the right 
tricle, and lastly, the right auricle and left auricle. 

The first change in this degenerative process is a loss of the nuclei of the 
primitive muscular fibres, with a simultaneous loss of their striated a] 
ance. Granules, completely filling the sarcolemma. make their appearance, 
and from having the look of albuminoid matter, change to fat-gramil. - 
oil-globules, rarely larger than a red blood-corpuscle ; they are generally ar- 
ranged in very nearly even rows, and at last absolutely till the sarcolemma. 

The normal size of the fibres remains unaltered and all the fibres are 
not affected to the same extent. 

Some have divided this degeneration into two forms : the granular and 
the fatty. But the former is more usually regarded as only d the 

latter. 

A heart which is the seat of this change is of a paler color than normal, 
more opaque, and its tissue is friable, breaking down with a soft, granular 
fracture ; there is a distinct loss of cohesion. The organ is usually r. 
in size (that is, the normal size for advanced life) : it may be hvjx rtrophied 
or dilated, the latter being the much more frequent condition. In some 



THE DISEASES OF OLD AGE. 227 

very old people the discolored and flabby heart is noticeably diminished in 
size. 

When the degenerative process is partial, the heart will collapse when 
removed from the body, and exhibit a mottled appearance, the spots vary- 
ing in color from a drab, gray, or dirty brown hue. 

These opaque patches are unevenly distributed over the heart, and occur 
in the papillary muscles, the columns corneas, and especially in the fibres 
just under the endocardium. They are readily broken by pressure of the 
linger, and under the microscope will show large oil-globules and fat- 
granules, many of which have escaped into the adjacent tissue. On section 
the blade of the knife is covered with the fatty material, and the organ may 
leave oil-stains on paper. This partial softening is so common at this 
period of life, that some French writers call it senile softening. 

The coronary arteries may be obliterated, calcified, atheromatous, or 
normal ; there being no necessary relation between abnormalities of these 
vessels and fatty degeneration of the heart, except when it is secondary to 
muscular hypertrophy. 

In fatty infiltration there is merely an increase of fat in the areolar tissue. 
Strise of fat may be seen lying among the muscles, or so thickly is the heart 
encased in it, that it seems to be but a mass of fat. This accumulation 
is always most marked at the external surface of the organ, diminishing 
toward the endocardium. It may establish true fatty degeneration, or 
fatty metamorphosis, by its pressure, and thus an in/ra-stitial may become 
an inter-stitidl process. 

This is sometimes called senile obesity of the heart ; and you will 
usually find in the hearts of old people depositions which are quite exten- 
sive around the base of the ventricles, in the line of junction between 
them and the auricles, and at the origin of the large vessels. 

Along the course of the coronary vessels the fat is contained in oval or 
round cells whose average diameter is about one one-hundredth of an inch. 
This differs markedly from true fatty metamorphosis. 

Etiology. — Fatty heart is essentially a disease of old age, although it 
may occur at any age. The liability to it steadily increases with advancing 
years. 

Fatty infiltration, overgrowth, or senile obesity occurs usually in those 
who have an excessive development of adipose elsewhere. It is twice as 
frequent in the male as in the female, and the influence of heredity cannot 
be doubted ; there is, in a large number of old people, a constitutional ten- 
dency either inherited or acquired. Sedentary habits exert a marked in- 
fluence in developing, or aiding the development of fatty infiltration of the 
heart. 

Fatty heart often comes on not only with senile marasmus, but also with 
thot marasmus accompanying Bright's disease, gout, phthisis, cancer, and 
chronic alcoholismus. It is worthy of remark that fatty heart from such 
causes seldom reaches a point where it seriously interferes with its action. 

In old age a very frequent cause of cardiac degeneration is interference 
with the coronary vessels. Such interference may be due to atheroma and 
calcification of these vessels, to embolic obstruction, external compression, 
from pericardial thickening, or impaired recoil of the aorta from any cause 
whatever. Poisoning from phosphorus or phosphoric acid, and perhaps dis- 
ease of the cardiac ganglia may lead to this diseased condition of the heart. 

Finally, in some instances, the causes of true fatty degeneration or 
metamorphosis of the heart must be regarded as yet undetermined. 

Symptoms.— -The objective signs of fatty degeneration of the heart in old 



228 CLINICAL LECTURES ON 

age are obscure. Indeed, some authors (Balfour among them) state that 
it cannot be recognized during life with certainty. Moderate fatty de- 
generation will go unrecognized, and sudden death may occur when there 
is no suspicion of its existence during life. The disease progresses slowly 
and gradually, and the symptoms vary in proportion to the extent of the 
process. 

The aged patient is incapable of attending to any business that requires 
the slightest physical exertion ; the muscular power is steadily diminished. 

The breathing is easily embarrassed, and tits of dyspncea and palpita- 
tion are easily induced, and during the paroxysms there may be acute pain 
and faintness, the attacks simulating those of angina pectoris, while tinni- 
tus aurium, giddiness, and other phenomena of a deranged cerebral circu- 
lation, are very common characteristics. 

During the parox}-sm the liver enlarges and the respiration becomes 
feeble and irregular, frequently sighing in character. 

Attacks of syncope, the result of cerebral anaemia, increase in frequency 
and severity as the disease progresses, and it is a peculiarity of fatty heart 
that the patient himself is aware, on a retrospective view, that there has 
been a steady and decided loss of muscular power. 

Independent of all ''anginal" attacks, you will now and then meet cases 
where pain is seated over the cardiac or sternal regions, or shoots down 
the arm during the greater part of the time ; it then becomes one of the 
most troublesome symptoms. 

The countenance is sallow, " pasty," or pale ; perhaps livid from venous 
stagnation; the extremities are cold, and, in a few cases, oedemaious. The 
tissues of the body are flabby and there are the usual evidences of arterial 
degeneration; arcus senilis is a valuable sign of this form of cardiac de- 
generation, being regarded by the older writers as nearly pathognomonic. 

In order that the arcus senilis shall be significant of cardiac degeneration, 
the ring must be well defined, rather yellowish in color, the remainder of 
the cornea being cloudy and opaque, a tinge of jaundice coexisting. 

Old people with fatty heart find their memory less retentive than in pre- 
vious years, and those about them notice a change in their disposition ; 
they are very apt to become morose, moody, irritable, and to have an ha- 
bitual depression of spirits. Derangements of the digestive organs, ano- 
rexia, and sometimes diarrluva and vomiting occur with senile fatty heart. 
The pulse is /critic, never strong, although it varies in force at dif 
times : at one time regular, at another irregular in both rhythm and force. 
The, irregularity is most apparent after sudden excitement or violent exer- 
tion. At times the pulse will beat very rapidly for a few moments, and then 
drop to thirty or forty per minute, becoming in such cases markedly ir- 
regular. 

The rule is that, in old age, fatty heart is accompanied by a slow, weak, 
and. irregular pulse. 

A. peculiar kind of dyspncea, the " Cheyne-Stokes dyspnoea," or M the as- 
cending and descending respiration," was formerly regarded as char 
istic of fatty degeneration of the heart This is not true, but it so fre- 
quently accompanies this disease that it is necessary to refer to it 

Cheyne, who first wrote about it nearly eighty years ago. thus describes 
it : ''For several days the patient's breathing was irregular : it would en- 
tirely ceaxe for a quarter of a minute, then it would become perceptible, 
though very slow. Then, by degrees, it became heaving and quick, and 
next would cease again. This revolution in the state of breathing occupied 
about a minute, during which there were about thirty i juration. '' 



THE DISEASES OF OLD AGE. 229 

Physical signs. — Inspection. — The apex-beat is seen faintly and indis- 
tinctly ; in extreme cases it is invisible. 

On palpation the hand will either detect no movement whatever over the 
precordial space, or the movements will be only occasionally felt, and then 
but very feebly. The impulse resembles that imparted to the hand by an 
aneurismal tumor. 

When dilatation coexists, a tumbling, rolling motion will be noticed, 
but this is a sign of dilatation, not of fatty heart. 

Percussion may elicit dulness over an abnormally large area, but this is 
from "obesity" or "fatty overgrowth" of the heart, or from pre-existing 
dilatation, which is so frequently associated with this form of cardiac de- 
generation. 

Auscultation. — The first sound of the heart will be feeble or absent. 
When audible it is entirely valvular, and is followed by a comparatively 
long period of silence. It is a "toneless" sound, and is higher-pitched 
than is usual in old age. Indeed, the shortening of and rise in pitch in 
the first sound may cause it to closely resemble the second. 

The second sound is feeble, and less distinct than the first. Rarely 
will you have murmurs in senile fatty heart, whatever may be the anatomi- 
cal condition of the valves. 

Temporary absence of the first sound may occur in senile ancemia and 
in some acute diseases of advanced life ; but the sound will return when the 
anaemia disappears, or during convalescence from the disease. Thus, a con- 
tinued absence of the muscular elements of the first sound becomes one of 
the most important signs of fatty heart. 

Differential diagnosis. — Cardiac dilatation is most likely to be mis- 
taken for fatty heart, and, indeed, the two often coexist. 

In dilatation, percussion elicits a well-marked increase in the area of 
cardiac dulness ; while in simple fatty degeneration the outline of the heart 
is shown to be normal. The first sound in dilatation may be feeble, but it 
is never absent, a condition frequently met with in senile fatty degeneration. 

There are few, if any, of the cerebral symptoms in dilatation which so 
constantly attend a fatty heart. The Cheyne-Stokes respiration and the 
arcus senilis are prominent in fatty degeneration, and do not occur in dila- 
tation of the heart. 

Symptoms of pulmonic obstruction and congestion will rarely be absent 
in cases of dilatation which will be likely to be confounded with fatty heart, 
while such symptoms are exceedingly rare in cardiac degenerations. 

Prognosis. — The prognosis in fatty heart is bad ; it is incurable. 

The fatal issue may be delayed when the cause can be removed, as in 
cases of chronic alcoholismus ; some claim that a condition of fatty heart, 
accompanied by a like degeneration of the vessels, is not without its ad- 
vantages, since a feeble heart is thus adapted to a feeble arterial system. 

Fatty degeneration of the cardiac wall may exist for years, but life is 
always insecure ; it is the fact that sudden death may occur at any moment 
which renders the disease so formidable. 

These patients become more and more feeble until, finally, general 
dropsy sets in, and asthenia closes the scene ; or more frequently syncope, 
coma, or rupture of the heart, unexpectedly cause the fatal issue. Rupture 
of the heart has no well-defined symptoms, and is immediately fatal. 

Treatment. — Nothing can restore a heart in the advanced stage of fatty 
degeneration. The age of the patient, the feeble heart, the cachectic condi- 
tion, all demand a supporting and a tonic plan of treatment. 

Iron, strychnia, cod-liver oil, a generous but easily assimilated diet, a 



230 CLLNTCAL LECTURES ON 

moderate allowance of some nutritious wine, as Burgundy, are the only 
means which we have for increasing and improving the tissue-making 
power. 

It is hardly necessary for me to say that when there is any palpable ex- 
isting cause, such as chronic alcoholismus, it must at once be removed. 
No violent exercise, no prolonged moderate exercise, no excitement can 
be tolerated by these patients without absolute harm. The patient must 
live the life of an invalid, and all hygienic measures must be strictly re- 
garded. The bowels must never become constipated, for straining at stool 
might cause rupture of the heart and death. 

Digitalis is of little service ; its administration, may, however, give tem- 
porary relief. 

In simple obesity of the heart, alkalies are believed to have a very favora- 
ble influence, and here the food must contain a minimum of hydrocarbons, 
and if an excessive amount of food has been taken, the amount must be 
restricted. Exercise may be allowed to a moderate degree, but our main 
reliance is on the diet. 

The attacks of syncope may be relieved by such stimulants as strong 
coffee and ether ; the nitrite of amyl relieves both the fits of dyspnoea and 
the suffocative oppression accompanying anginal pain. 

To relieve pain by narcotics is a dangerous procedure under these cir- 
cumstances ; hypodermics of morphia have been followed by instant death, 
as also have inhalations of chloroform ; ether is perhaps the least dan- 
gerous. 

The treatment is purely palliative, and the prolongation of life dejiends 
on the ability of the patient to so regulate his diet and surroundings, and 
to spend so much of his time in the oj>en air as his particular ms to 

require. 



THE DISEASES OF OLD AGE. 231 



LECTURE XXVII. 

CEREBRAL HEMORRHAGE.— APOPLEXY. 

Summary.— Morbid Anatomy— Etiology— Symptoms— Differential Diagnosis— Progno- 
sis— Treatment— Cerebral Softening— Ramollissement— Morbid ° Anatomy— Eti- 
ology. 

Gentlemen : — By the term cerebral hemorrhage is understood an ex- 
travasation of blood within the cranial cavity. The term apoplexy, literally 
means the results produced by the extravasation of blood into brain-tissue ; 
but it is often applied to those extravasations which are serous, as well as 
to those which are sanguineous. Hemorrhages, the result of traumatism, 
are not included under the head of apoplexy. 

Morbid anatomy. — There are two varieties of cerebral hemorrhages: 
one consisting of minute blood-extravasations, or points ; the other of 
clots of varying size. 

Preceding either form, the vessel ruptured is the seat of miliary aneu- 
rism ; these aneurismal dilatations upon the arteries are caused by a peri- 
arteritis, commencing in the lymph-sheaths of the vessels and advancing 
to the tunica adventitia and the muscular coat. 

Minute blood-extravasations play an important part in the development 
of apoplexy. Little foci sometimes occur within the cortex of the brain as 
the result of venous thrombi, but these are probably soon absorbed. You 
may find them accompanying cerebral softening, and also in the neighbor- 
hood of large apoplectic spots. A congregation of these pin-head extravasa- 
tions may constitute apoplectic foci. 

At an autopsy we usually find irregularly spherical clots of blood, varying 
in size, but usually about three-fourths of an inch in diameter, imbedded 
in the cerebral substance. 

In the aged, often a large portion of the brain is occupied by the 
extravasation. 

The favorite localities for these hemorrhagic extravasations are the in- 
traventricular nucleus of the corpus striatum, the extraventricular nucleus, 
the thalamus opticus, the cerebellum, and the pons. More frequently in 
the aged than in others will you find the corpus striatum pushed up and 
surrounded by the extravasation, instead of having an effusion into it ; this 
is best seen in the ventricles, which may also be the seat of hemorrhage, 
sometimes so extensive that their septa are torn and blood escapes upon 
the surface of the brain. 

In the aged you will quite often notice apoplectic foci between the mem- 
branes in the subarachnoidean space, or even superficially. The locality of 
the extravasation is determined by the arterial distribution, as the vessels 
to those parts already named are the most direct continuation of the 
carotids. 

The cerebral convolutions are flattened and the sulci deepened when 



232 CLINICAL LECTURES ON 

the extravasation is extensive ; the dura mater is stretched, and sometimes 
there is a visible bulging, for, in advanced life, large hemorrhages are 
rather the rule. The clot, or "focus," is a soft, grunious mass, at whose 
centre is the opening into the ruptured vessel. Its wall consists of shreddy, 
cerebral matter, mingled with fibrinous fibrilhe, the result of the hemorrhage. 

When the apoplectic stroke, as it is called, is not immediately fatal, 
the clot may undergo three changes : 1st, its fluid may be absorbed ; 2d, 
it may undergo fatty degeneration and be absorbed ; 3d, it may excite in- 
flammation in the surrounding brain-substance, and lead to red softening. 
In all cases the brain-substance in the immediate vicinity of the clot is 
somewhat cedematous, and slightly yellowed. 

The secondary changes consist in the transformations of the clot into a 
cyst, whose contents vary in color from a pale yellow to a dark brown, 
according to the number of blood-corpuscles that undergo pigment de- 
generation. The cyst-wall is firm, smooth, connective tissue. A cyst 
rarely becomes an abscess of the brain in the aged. 

Cicatricial tissue may forni from the cyst, although it is, at present, a 
mooted question whether a cyst must necessarily pre-exist in order that 
such a cicatrix shall form. It takes about two years, in old people, for 
such a cicatrix to fomi and the cyst to be absorbed. There may be a 
number of these cysts or cicatrices in the same brain, corresponding to 
the number of apoplexies. Crnveilhier states that he found fifteen in one 
brain. They cause " puckering " of the brain-substance. 

The nerves connected with the parts involved may undergo degenera- 
tion, and general atrophy of the brain may ensue. 

Etiology. — Tho most powerful predisposing cause to cerebral hemor- 
rhage is age. It rarely occurs before forty, the liability to it increasing 
with advanced years. It is generally stated that the tendency ceases at 
about seventy; but this is not so, for the comparatively small number of 
people living over seventy has not entered into the statistical estimate. 

The causes which predispose to apoplexy are fatty, atheromatous, or 
fibroid degeneration of the walls of the vessels ; hence, the importance of 
gout, rheumatism, syphilis, alcoholismus, and chronic Bright's disease as 
predisposing causes. 

Cardiac hypertrophy and dilatation predispose to apoplexy ; aortic in- 
sufficiency and pulmonary emphysema are also important etiological factors. 

Softening of the brain, which, I think, follows as often as it prei 
apoplexy, also predisposes to it. 

Men are far more liable to cerebral hemorrhage than women, on account 
of their active mode of life and their greater liability to excitement. Apo- 
plexies also occur much more frequently in cold than in warin weather. 

The exciting causes may be summed up in the phrase, dm \oodr 

pressure : although a cerebral hemorrhage may occur without any such in- 
crease, at least so far as we can discover. Coughing, running, a fall, 
violent emotion, the venereal act (the latter especially) are frequently 
exciting causes of apoplexy in the aged. A cold bath, by constringing 
the cutaneous vessels, may be an exciting oaO£ 

The so-called "plethoric habit." which causes in some so much anxi 
has no significance, for the emaciated valetudinarian is just as liable to 
apoplexy as he of the opposite condition. 

There is in certain persons an hereditary tendency to arterial degenera- 
tion which predisposes to cerebral hemorrhage. 

Symptoms. — There may or may not be prodromata of a cerebral apo- 
plexy. When the latter are present they may appear either in the form of 



THE DISEASES OF OLD AGE. 233 

vertigo, muscse volitantes, double vision, temporary blindness, tinnitus au- 
rium, complete deafness, an abnormally keen sense of smell, or a total loss 
of it. These are, however, unimportant, compared to loss of memory, diffi- 
culty of speech, lethargy, or stupor, and a feeling of weight, numbness, or 
formication that very commonly presages a fit of apoplexy, and which 
should always excite alarm when present during the senile period of life. 
Bepeated epistaxis is another important prodromal symptom. 

These premonitory signs may be* absent, and the attack be instan- 
taneous, the patient suddenly falling into a condition of coma, with loss of 
sense, sensation, and voluntary motion ; or, the coma comes on gradually, 
being preceded by pains in the head and a feeling of faintness ; or, finally, 
aphasia and hemiplegia are the first and the only symptoms. 

The attack may be so light as to seem nothing more than a momentary 
state of insensibility ; and the patient is thought to have had " a fainting- 
spell " or " a fit of indigestion," since it frequently comes on after an aged 
person has been over-indulgent at table. 

Usually, however, the individual is struck down suddenly, and there 
is complete loss of consciousness for a period varying in length from a few 
minutes to two or three days. 

During the state of coma the respirations are deep, slow, and often ster- 
torous ; the face is either pale, or red and turgid ; the veins are engorged, 
and as the coma deepens the face assumes a dark, livid hue. A marked 
pallor may sometimes continue through the whole attack. If the coma 
last three days, the temperature on the second day is lowered (96° F.) 
frequently to rise the next day to 107° F. The pulse in old people at the 
onset of the "fit " is commonly rapid, feeble and intermittent ; later it be- 
comes slow, full, and regular. As a rule, the pupils are dilated, though at 
times, while one is of normal size, the other is dilated or contracted. 

In its worst ioYm—" apoplexie foudroyante" — the breathing is exceed- 
ingly slow, stertorous, often superficial, interrupted, and irregular. Each 
expiration is accompanied by a loud " puffing " noise from the lips, and the 
ejection of a frothy mucus which accumulates about the mouth. Degluti- 
tion is impossible ; the features are distorted, the pupils contracted, the 
skin is cold and clammy, and the fseces and urine are passed involuntarily. 
Death usually occurs, in such cases, in two or three hours. Keflex move- 
ments may be excited, except in very rare instances. The paralyzed side is 
usually convulsed from the beginning, and tetanic spasm of a muscle, or 
set of muscles, occasionally occurs. 

There is a form of apoplexy which is sometimes observed in the aged, 
seemingly associated with ventricular effusion— -a general convulsive attack, 
epileptic in character, where the tongue is often bitten and frothing at the 
mouth occurs, lasting from fifteen to thirty minutes, which is followed ap- 
parently by no bad results other than the gradual supervention of extreme 
debility. But death almost always ensues after a longer or shorter period 
varying with the age and constitution of the patient. 

Apoplexy in the aged, is synonymous with hemiplegia, and its evidences 
are too well-marked to need any lengthy description. The " conjugate de- 
viation" of the eyes, the protrusion of the tongue toward the paralyzed 
side, the drawn mouth, etc., these are the common symptoms. Anaesthesia 
on the paralyzed side commonly occurs, but passes off gradually in most 
cases. 

The hemiplegia itself is permanent or temporary, depending on com- 
plete destruction or only partial implication of the corpus striatum or 
thalamus opticus. 



234 CLINICAL LECTURES ON 

I shall not attempt to name all the variations due to hemorrhages into 
the pons, cerebellum, etc. 

Differential diagnosis. — Cerebral hemorrhage in the aged may be mis- 
taken for cerebral congestion, uraemia, alcoholic intoxication, and embolism. 

In congestion there is absence of stertorous breathing, which is always 
present in apoplexy. 

The pupils are contracted in congestion, and dilated in apoplexy. 

The coma is of very short duration in congestion, whereas it persists 
for some time in apoplexy. 

Congestion has a long prodromal period ; while it is short, and often 
absent, in cases of apoplexy. 

In congestion the paralysis is usually bilateral, while ' in apoplexy it is 
unilateral. 

Hemiplegia is rarely present in uraemia, while it is rarely absent in 
apoplexy. 

Uraemia comes on gradually, and is usually preceded by convulsions ; 
while the coma of apoplexy is sudden in its advent, and convulsions never 
precede it 

The presence of casts and albumen in the urine establishes the diagnosis 
between uraemia and apoplexy. 

Alcoholic intoxication is often mistaken for apoplexy. The patient can 
easily be roused from alcoholic coma, while this is not the case with cerebral 
hemorrhage. 

There is no stertor in alcoholic coma, whereas it is usually present in 
uraemia. 

The pulse is feeble and frequent in alcoholic coma, while it is full, 
strong, and slow in apoplexy. 

There is no hemiplegia in alcoholic coma, while it is an exceedingly 
common condition in apoplexy. 

Lastly, the urine may be tested for alcohol as follows : to fifteen min- 
ims of a solution consisting of three hundred parts of strong sulphuric 
acid, and one of bichromate of potassa, add a few drops of the suspected 
urine ; in case of alcoholism, the mixture tarns an emerald green. 

Cerebral embolism rarely occurs in the aged, and is accompanied by 
tory of rheumatism or rheumatic endocarditis and valvular disease of the 
heart. In embolism, the patient does not lose consciousness ; in apoplexy 
there is loss of consciousness. The pulse is rapid and feeble in embolism, 
and the face is pallid ; in apoplexy the pulse is slow and full, the face is 
red and turgid. Aphasia is rare in apoplexy, while almost pathognomonic 
of embolism. 

The pupils are unaltered in embohsm, while in apoplexy they are usually 
deviated from the normal. 

There is stertor in apoplexy, whereas in embolism the breathr. 
normal. Paralysis is usually on the right side in embolism, while it is 
on either side in cerebral hemorrhage. Evidence of arterial atheroma is 
usually present in apoplexy, it may be absent in cases of embolism. The 
paralysis improves in forty-eight hours, in embolism, while in apopk 
is of much longer duration, and is rarely entirely recovered from. 

Prognosis. — The prognosis in the apoplexy of old age is always grave. 
If the first attack is recovered from, it is almost always followed I g 
within a year ; a third attack is almost always fatal. 

The greater the age, the greater the danger. 

Persistent coma, loss of control over the sphiucters. dysphagia, " pin- 
head "pupils, a temperature over 100° Fahr., and a "puffy " expiration, are 



THE DISEASES OF OLD AGE. 235 

all unfavorable symptoms ; and convulsions, indicating that the hemorrhage 
has involved the meninges, are generally soon followed by death. 

The general condition of the patient, and his freedom from disease, will 
likewise influence the prognosis. Never give a positive prognosis until at 
least two weeks have elapsed after the attack. 

Even after so-called recovery has taken place in the aged, there is more 
or less loss of mental power, so that the patient is incapable of transacting 
business accurately, and even the power of reading, or the memory of cer- 
tain words, is wholly lost. The more complete the paralysis, the less the 
chance of recovery. 

Treatment. — The prophylactic treatment resolves itself into avoidance of 
sudden violent physical exertion, or of strong emotion. The diet should 
be simple and non-stimulating. The clothing should be worn loosely, and 
there should be free ventilation in the living and sleeping apartments. 

Sudden extremes of temperature should be avoided ; hence, hot and 
cold baths are contraindicated. Attention must be paid to the bowels, 
and, in the advent of premonitory symptoms, active purgation and blisters 
to the neck will be found of service. 

Alcoholic beverages in excess are most harmful, but light wines, in 
moderation, do no injury. 

The bromides of lithium and zinc oxide are often administered with 
advantage when cerebral hemorrhage threatens. Finally, remember that 
you are dealing with old age, and that the patient must not be debilitated. 

When an attack or " stroke " has occurred, the first things to be done 
are to elevate the patient's head, loosen the clothing about the neck, and 
have the apartment kept dark and absolutely quiet. The air about the 
head may be kept cool by ice-bags, and the feet are to be placed in a hot 
mustard-bath. 

Under no circumstances should bloodletting be practised in the treat- 
ment of apoplexy of old age. 

The bowels should be moved by drastic cathartics, sufficiently to induce 
the so-called "revulsive" effects. 

Much of the venous turgescence of countenance may be due to stertor 
from falling back of the tongue ; hence, place the patient on his side, and 
it will frequently disappear. Emetics are never to be administered. Sina- 
pisms may be applied to the nape of the neck, calves of the legs, and over 
the stomach, their size and number being determined by the condition and 
age of the patient. 

When the vital powers are greatly depressed, when there is extreme 
feebleness and pallor, internal and external stimulation must be resorted 
to ; milk, beef-tea, and brandy are to be given freely. Iron can be ad- 
ministered to the aged in nearly all cases of cerebral hemorrhage^ The 
"hydropathic" treatment is now seldom resorted to for the hemiplegia 
which follows apoplexy in the aged. Mild narcotics are to be given in case 
there is much sleeplessness and irritability, but only after a lapse of two or 
three weeks. 

W T hen all symptoms of cerebral irritation have passed, faradization may 
be employed ; and phosphorus and strychnia (the latter hypodermically) 
may be given with advantage. 

I now invite your attention to the study of senile softening of the brain. 



236 CLINICAL LECTUEES ON 



Cekebral Softening. 

Cerebral ramollissement, or encephalomalachia, is a disease peculiar to 
old age. It is one of the most frequent cerebral diseases of advanced 
life. 

Morbid anatomy. — This condition has, in reality, been studied only with- 
in the present century ; and many theories have been advanced as to its 
nature and pathogenesis. Some claim that it is always the result of inflam- 
mation ; others say it is a variety of gangrene ; arid still others, that it is 
the result of a chemico-pathological process. 

Three forms are discoverable at the autopsy : the red, the yellow, and 
the white softening. The red has been called acute or inflammatory ; and 
the white, chronic or non-inflammatory softening, though this distinction 
cannot always be demonstrated. 

I. — Red softening is first marked by stasis, rapidly followed by fatty de- 
generation of the cells and nerve-fibres. The pultaceous tissue is of a deep 
red color, or the discoloration may occur in sj)ots as numerous foci in dif- 
ferent stages of softening, the processes in either case being best marked 
at the centre of the softened mass or masses. The vessels are filled with 
coagulated blood, their contents undergoiug a retrograde nietainorphosis, 
and the fibrin becoming granular, the infarction becomes dry and shrunken, 
cicatrization may occur, or there maybe liquefaction of the content- 
the formation of cysts. Increase in specific gravity in red softening occurs 
in a few instances, although decrease is the rule. 

The microscope reveals the presence of fat-granules, altered blood-cor- 
puscles, and large granular corpuscles ( Oluge't corpuscles) from the cells of 
the neuroglia. The capillaries are dilated and tilled with coagula. and the 
white substance of the fibres is coagulated or broken up into large masses 
of myeline. 

This variety of cerebral softening is properly called : its 

color is due to its sudden occurrence, the subsequent pathological change! 
being common to all {Jure form*. 

II. — The softening from anamiia, i.e., from obstruction in the vesst 
called yellow softening. It may occur at any point in the brain, but its 
most frequent seat is in the middle or posterior lobes, and in the convolu- 
tions or corpus striatum. It is often the color of sulphur, varying in size 
from that of a hazel-nut to that of the fist ; it may involve a whole hemi- 
sphere. Its consistence varies, but in typical cases it is a gelatinous, 
moist, and tremulous pulp. Later on the so-called "cellular infiltration " 
of the French writers occurs : the implicated spot is metamorphosed into 
a mass of reticulated fibres, in whose meshes is a milky, chalky fluid. This 
is a sort of reparative process, having its analogue on the surface of the 
brain in the yellow plaques made up of tough, pliable, ochre-colored con- 
nective tissue containing nuclei, crystals of haematm and hirmatoidin, and 
a few fat-corpuscles. When cut across, one of these spots rises above the 
level of the section ; a gentle stream of water will wash away the softened 
tissue from the surrounding cerebral substance. In all varieties of soften- 
ing there is usually no well-marked line of demarcation : the healthy and 
diseased parts insensibly run into each other. In the yellow variety we 
can occasionally find traces of demarcation. 

The color of yellow softening depends on a closer congregation and ■ 
finer subdivision of the fat-globules than occurs in white softening, though 
changed blood-pigment sometimes gives it its yellow color. 



THE DISEASES OF OLD AGE. 237 

HI.— White, atrophic, or chronic softening is the variety most frequently 
met with in the aged. 

It is white, or resembles healthy brain-tissue, for the reason that the 
process takes place slowly, and hence hyperemia or hemorrhage is very 
slight or wholly absent ; often the implicated spot is as difnuentas cream. 
The other pathological appearances are the same as in yellow softening, 
with which it is identical, except in color. 

There is a decrease in the specific gravity of brain-tissue that has un- 
dergone white ramollissement. 

Etiology. — I have said that the difference between red and white or 
yellow softening, as marked by the terms acute and chronic inflammatory 
and non-inflammatory, is not exact. Its etiology will explain this. 

Encephalomalachia is frequently the result of embolism, thrombosis, or 
hemorrhage. And since almost all the predisposing causes of thrombosis 
are met with in advanced life, thrombosis is by far the most frequent cause. 
It sometimes results from syphilitic disease of the arteries. 

It is quite well established that in advanced life severe and prolonged 
intellectual efforts or exercise of the emotions will cause cerebral softening ; 
blows, or the action of intense cold on the head, and alcoholismus act also 
as causes. 

Atheroma in predisposing to thrombosis is a powerful factor, and the 
pressure of intracranial tumors has been known to produce ramollissement. 
•Cardiac valvular diseases exert a most powerful influence in the develop- 
ment of cerebral softening. 

The liability to cerebral softening steadily increases with advancing age. 

Bed softening may be caused by embolism or thrombosis, and is then 
sudden ; or the vessels in chronic white softening may rupture, and the 
blood extravasated give a red color to the softened mass. 

Yellow softening may be, and commonly is, as I have said, a variety of 
white ; in some instances it primarily results from embolism or thrombosis ; 
a gelatinous oedema about cerebral neoplasia has been denominated a yel- 
low softening. 

White softening may in rare instances be acute, from a sudden obstruc- 
tion by an embolus in one of the larger arteries ; it may be due to the 
senile change in the vessels, and it may result from feeble heart-power. In 
some instances there is no discoverable cause. 

At my next lecture I shall speak of the symptoms and diagnosis of cere- 
bral softening. 



238 CLINICAL LECTURES ON 



LECTURE XXVIII. 



CEREBRAL SOFTENING. 



Summary. — Symptoms — Differential Diagnosis — Prognosis — Treatment — Senile Cere- 
bral Atrophy — Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — 
Prognosis — Treatment. 

Anatomicnl and Physiological Changes in the Alimentary Canal in Old Age. 

Chronic Senile Gastric Catarrh ,,Dyspepsiaj — Morbid Anatomy — Etiology — 
Symptoms — Differential Diagnosis. 

Gentlemen : — In acute cerebral softening prodromal symptoms frequently 
exist. These premonitory si, similar to those of apoplexy ; although 

formication, aching, and cramps of the limbs, and anomalies in the sense of 
touch, are much more prominent in commencing ramollissernent. Local 
inequalities of temperature are occasionally among the prodromata. There* 
is also a diminution in the motor power ; when thw in im- 

portant sign. "When prodromata occur, the symptoms either gradually in- 
crease, or else advance by sudden exacerbations with intervals of apparent 
improvement — the affected side grows weaker and weaker, the lingers, 
hands, and feet are managed clumsily, the leg trembles under the body, 
there is a tottering gait, and, finally, decided para 1 ,; 

It now either assumes the " chronic '* form, or typhoid svmptoms come 
on, and death speedily occurs, often from complications in the n 
organs ; the older the patient, the less likely are we to have premonitory 
signs. Often the attack simulates cerebral hemorrhage so closely that a dif- 
ferential diagnosis is impossible. 

In acute cases, withoui prodromata, the patient becomes suddenly para- 
lyzed without loss of consciousness, or is paralyzed and comatose ; but he 
soon comes out of the coma with impaired or l<>*t speech. Y 
very constant symptom, and when headache is present on the side opposite 
the paralyzed one, it is almost diagnostic. 

In some cases a mild delirium, a "wandering" as it is called, of - 
duration may mark the onset ; this occurs most frequently in very old per- 
sons. The eyeballs are directed to one side, although the featun 
metrical until active movements are made. 

Muscular rigidity, spasmodic twitching, difficult deglutition, suffusion of 
the eye, are usually present ; the urine and faces are passed involuntarily, 
bedsores form, the pulse grows more rapid and feeble, and the patient 
finally dies from exhaustion. 

Chronic softening is for weeks or months preceded by gradually increas- 
ing feebleness, loss of memory, fretfulness, and tits of uncontrollable 
weeping — rarely laughing. There are dull pains, or M a sense of confoe 
in the head : there is general loss of muscular power, with difficult 
"thickness" of speech. The patient becomes perfectly listless and tl. 
a marked change in disposition. Then comes partial paralysis of one 
side, and finally the patient becomes perfectly helpless and childish, and 



THE DISEASES OF OLD AGE. 239 

lie is incapable of retaining the contents of his bladder and rectum. 
Aphasia, from plugging of the left middle cerebral artery, is a symptom 
which frequently accompanies chronic softening. When paralysis begins at 
the distal end of a limb and approaches by degrees the trunk, it is called 
" creeping palsy." 

The intellect is much oftener affected in chronic than in acute ramollis- 
sement, and febrile symptoms are exceptional occurrences. 

The bowels are commonly constipated, the appetite and the body weight 
usually remain at the normal standard, and the patient is disposed to sleep 
the greater part of his time. In some cases there are no symptoms to 
mark its presence. 

Differential diagnosis. — The differential diagnosis between cerebral soft- 
ening, apoplexy and embolism we have already considered. 

In some instances the symptoms which attend the development of tumors 
of the brain may be mistaken for those of cerebral softening. 

The history, in cerebral softening, usually elicits cardiac disease or 
atheromatous arteries ; while carcinoma and gummata, the most frequent 
senile cerebral neoplasia, will probably have a history of syphilis or cancer. 

Localized pain in the head is a prominent and almost constant symp- 
tom in cerebral tumor, while the headache is dull and diffused, often absent, 
in softening — pain is not a necessary symptom of softening ; this is one of 
the chief points of its diagnosis. 

The speech and intellect are unaffected in tumors ; whereas both are 
early implicated in cases of softening. 

Symptoms referable to some special cranial nerve or set of nerves are 
present in cases of cerebral tumors, and absent, as a rule when softening 
exists. The face is prominently implicated in the paralysis from tumors, 
while hemiplegia is the rule with softening. 

Epileptic convulsions, independent of paralysis, occur frequently with 
tumors, but they do not exist in cases of cerebral softening. 

If tumors are syphilitic, the symptoms which they give rise to improve 
under large doses of iodide of potassium, while this drug has no effect in 
cerebral softening. 

Prognosis. — Senile cerebral softening is regarded as inevitably fatal. 
In acute softening death has often occurred on the first day, and life is not 
prolonged over ten days. 

Chronic cerebral softening is very varying in its duration ; cases have 
been reported where the symptoms were well marked and extended over a 
period of four years. 

Death may directly occur , from the softening, either from interference 
with respiratory apparatus, or from the complications, such as bronchitis, 
pneumonia, meningitis, hypostatic congestion of the lungs, diarrhoea, ex- 
tensive sloughs on the sacrum and hips, hemorrhage into the softened 
mass, or from exhaustion. 

Treatment.— When the premonitory symptoms of cerebral softening oc- 
cur the strictest attention must be paid to the diet, which must be simple, 
nutritious, and easy of digestion. The surroundings of the patient should 
also be regarded, and no excitement or over-exercise allowed. These 
patients should never be allowed to become constipated. Milk is the best 
article of diet in these cases. 

When there is excitement followed by sleeplessness or headache, the 
bromides may be administered ; and Indian hemp is regarded by some as 
a most useful drug in this condition. 

When softening is established, benefit is often obtained from zinc, phos- 



240 CLINICAL LECTURES ON 

phorus and strychnia, and the tonics iron and quinine are beneficial in 
nearly every case. The constant current, alternating with faradization, is 
to be given with great care. 

When cerebral softening simulates apoplectic seizures, the same recum- 
bent posture, cool surroundings, quiet, etc., must be preserved as were 
advised in cerebral hemorrhage, and the bowels must never be allowed to 
become constipated, you will find this to be the tendency in the vast 
majority of cases. When bedsores and sloughing threaten, they must be 
promptly combated, for the strength of the patient is greatly diminished 
by them, and in the aged they are very obstinate and often cause death. 

Blistering, counter-irritation and bloodletting are contraindicated in all 
cases. 

The last senile cerebral disease which I shall consider is 



Senile Cerebral Atrophy. 

Morbid anatomy. — In senile atrophy there is actual diminution in the 
cellular elements of the brain, and a loss in its interstitial connective 
tissue. The cells of the cortex are swollen and pigmented, and pigmenta- 
tion also occurs in the walls of the vessels which are commonly the seat 
of fatt} r degeneration. Corpora amylacea are present in the vast majority 
of cases, especially in the thinned cortex. In general it may be said there 
is decrease in the fat, and increase in the water of the brain-substance. 

Senile atrophy is usually complete ; when partial it affects the left 
hemisphere. There is unequal thinning of the convolutions, and the sulci 
are larger and deeper. There is increased consistence, often long! 
of the brain, the meninges are clouded, and the ventricles are dilated with 
fluid, varying in amount from two to twelve drachms ; this must 1 
garded as a purely conservative process. Serum likewise fills the subaraeh- 
noidean space. 

An attempt to cut the brain shows it to have a leathers- tough 
and the section is frequently corrugated : the medullary portion will have 
a dull white or drab color, and the cortical substance will be darker than 
normal. 

Cases occasionally are found where the arachnoid covering the hemi- 
spheres is in juxtaposition with that of the ventricles, there I 
substance between : again, only a thin layer of areolar tissue may intervene 
between these two membranes. 

Etiology. — Atrophy may follow a hemorrhage or softening, and is occa- 
sionally caused by tumors and inflammation of the coverings of the brain. 
Injury or destruction of the peripheral nerves may induce secondary 
bral atrophy. But the great cause is senile marasmus. 

Symptoms. — The mental faculties in senile cerebral atrophy gradually 
become weaker and weaker ; there are loss of memory and blunting of the 
special senses ; and the movements, from being unsteady, are soon accom- 
panied by tremor. 

The patient becomes childish, apathetic, and is constantly sleepy or 
asleep, and nearly all control over the sphincters is lost. 

The disease finally ends in invasion of the medulla, implication of the 
centres situate therein, and deglutition or respiration, or both, ai 
much interferred with, if not annulled, as to cause death. 

It may be that general paralysis of both sides of the body occurs, and 
then complete imbecility usually supervenes. 



THE DISEASES OF OLD AGE. 241 

Differential diagnosis. — This is made from softening and hemorrhage 
only, by exclusion and a careful consideration of the history. 

Prognosis.— -This is always unfavorable ; no estimate can be made as to 
the length of life, and the intellect and forces cannot be rallied by any known 
means. Its duration is uncertain. 

Treatment. — Treatment is out of the question ; we can only build up 
the patient by means of a good diet and tonics. 

I shall now pass to the consideration of senile diseases of the digestive 
apparatus. The most common and important of this class is 



Chronic Senile Gastric Catarrh. 

The digestive apparatus participates in the general atrophy which occurs 
in all the tissues in old age. The stomach and intestines lose bulk, and 
their mucous membrane is markedly thinned. 

The glandular system is more or less atrophied, and many of the glands 
seem to have entirely disappeared. Not only is the gastric mucous mem- 
brane thinned, but it is also paler than in adult life, usually acquiring an 
ashy gray color, which is more pronounced the older the individual. 

The vessels of the mucous membrane, the veins especially, are dilated 
and varicose. The glands in the stomach are occasionally so impregnated 
with melanin that they have a punctated look, resembling the cutaneous 
surface when filled with specks of gunpowder. Numerous small yellow 
spots (groups of glands filled with fatty matter), occur in the gastric mu- 
cous membrane in that condition known as senile marasmus. The duo- 
denum, jejunum and ilium undergo more extensive wasting of their coats 
than occurs in the stomach ; indeed, these structures are sometimes so 
attenuated that at the autopsy their contents are distinctly visible through 
their walls. 

It may be mentioned that the large intestine does not exhibit so much 
wasting, since there is more or less compensatory hypertrophy of its mus- 
cular coat. 

Atrophy of the jaws, the lower especially, results from loss of the teeth, 
a common condition in old age ; and even on the surface of the tongue we 
find that thinning of the digestive mucous membrane already referred to. 

The physiological results of these conditions are a blunting of the sense 
of taste, more or less dysphagia, and difficult mastication ; a slow and im- 
perfect stomach and intestinal digestion. 

As old people lose their teeth and their power of mastication, they con- 
sume less bread and meat, as well as other solid food ; hence, chronic 
anaemia becomes a physiological condition in many old people. The re- 
sult of all these changes is a diminution in the absorption of nutritious 
elements. 

In this connection, it may be stated that in old age the bile is much 
richer in cholesterin than in adult life. The salivary glands, the pancreas, 
and the mesenteric glands share in the general glandular atrophy. 

Senile gastric catarrh, known also as chronic gastric catarrh of the stom- 
ach, catarrhal gastritis, and follicular dyspepsia, is very frequently met 
with in advanced life. 

Morbid anatomy.— You find, on examination of a stomach which is the 
seat of these changes, no such thick layer of mucus as is present in the gas- 
tric catarrh of adult life ; it must be remembered that the secretion of 
mucus is very much diminished in old age, both as a result of the senile 
16 



242 CLINICAL LECTURES ON 

state, and also as a result of diseased process. Some mucus, however, is 
found in every case. There are sometimes ecchymotic spots on the mem- 
brane, the result of hemorrhages from the varicose vessels. 

The color of the mucous membrane varies ; sometimes it retains its 
natural color, but oftener it assumes a reddish brown, slaty gray, or dirty 
blue appearance. 

The membrane is unevenly thickened, tougher than normal, and is very 
loosely connected with the cellular tissue beneath. In old age it is often 
corrugated, or thrown into furrows ; and villous projections one-fiftieth of 
an inch in height, filled with granular corpuscles, are found near the pylorus. 

Mucous polypi are almost exclusively limited to the stomachs of old 
people with chronic gastritis ; they are either sessile or pedunculated, and 
their nature and consistence vary according as they are composed of fibrous- 
tissue, papilke cysts of the obstructed glands, or of all these united. 

"Ulceration, thickening, and induration of the diseased membrane is of 
frequent occurrence, the ulcers being superficial, limited to the mucous 
coat, and, by their aggregation, a large extent of the membrane may suffer 
abrasion. 

"When the disease has existed for a long time, the mucous membrane has 
a granular or mammillary appearance which results either from obstruc- 
tion to the exit of the secretion from the tubules (thus causing tbem to 
stand out on an atrophied tissue), or mammillation may result from actual 
hypertrophy of the glandular layer. The microscope may show the tubules 
to be completely filled with fat-globules, or the epithelium to have under- 
gone fatty degeneration. 

In other cases the tubules will be found filled witli a granular detritus, 
and their epithelium will have undergone granular degeneration, which at 
the base is sometimes darkened by blood-stains. 

In whatever condition their contents may be, the mMOOUM foU 
vile chronic catarrh arc always enlarged, sometimes visibly so. By many 
these are regarded as the est 4 of the dtMHA In long-continued 

gastritis the submucous coat becomes involved, and more or less thickening 
and congestion occur in it. If there is an infiltration into this layer, its 
organization and subsequent contraction may hinder still more the peri- 
staltic motion already impeded to a greater or lesser extent by the senile 
intestinal changes already referred to. 

In many old people who have for years suffered from this disease, you 
may even find the muscular coat involved in the process of thickening, and 
this additional pathological lesion will reduce peristalsis to a minimum. 

Etiology. — Undoubted examples of primary acute or subacute gastritis 
are seen in old age. These are very rare, however, at this period of life, 
and may be thrown out as etiological factors, senile gastric catarrh being 
chronic from its commencement. 

Catarrhal dyspepsia is in old age very frequently associated with, and 
appears to be secondary to chronic bronchitis, bronehorrha-a, and chronic 
disease of the heart. One very important cause is ana?mia ; the senile 
anreniic condition which I have already referred to. 

Long-continued, passive hyperemia, the result of obstruction to the 
portal circulation and pressure froin tumors, acts as a producing c 
though not as frequently as chronic bronchitis and organic t the 

heart. Many old people will give such a clear history of ancestral dys- 
pepsias that there is no doubt but that the disease is sometimes hereditary. 

Old people who habitually eat too rapidly or too much, or wb< 
large quantities of food which in youth their stomach could manage, but 



THE DISEASES OF OLD AGE. 243 

■which, at this period of life, is utterly indigestible, always have embarrassed 
digestion, or, as they prefer to call it "a morbidly sensitive stomach." 
Again, unless the greatest care be taken, even slow and moderate eaters will, 
when their teeth drop out or decay, suffer from this painful condition on 
account of insufficient mastication. Immoderate smoking or snuff-taking 
may, in advanced life, induce catarrhal dyspepsia. 

Finally, alcoholic beverages, too little exercise, mental strain or physi- 
cal labor immediately after taking food, and irregularity in the time of 
eating, are very often followed by " dyspeptic " symptoms in the senile 
period of life. Scrofula, syphilis, and gout, undoubtedly predispose to, 
and the latter actually excites senile chronic gastritis. 

Symptoms. — In old age, you will find that chronic catarrh, or, as it is 
usually called, " dyspepsia," appears in a variety of ways. Some old people 
say their stomach was always weak, or that certain articles, mentioning 
those which they eat most of, always disagreed with them. Others, 
again, are truly great sufferers, and in them the condition amounts to more 
than an infirmity of advanced life. There is generally a sense of weight 
and fulness in the region of the stomach, either constant, or coming on 
in from one-half to an hour after the ingestion of food. 

Anorexia is present in nearly all cases of well-developed senile gastric 
catarrh, and the only food that is relished is that of a piquant and highly 
seasoned kind ; they cannot bear oily food. This anorexia soon leads to 
a well-marked anaemic condition, and to an exhaustion which is far more 
dangerous than the emaciation accompanying it ; thus, anorexia must be 
looked upon as a serious symptom, and one to be promptly combated. 
Accompanying the anorexia there is commonly great thirst, especially for 
acid drinks. 

Old people with catarrhal dyspepsia vomit, or rather regurgitate, every 
morning, or at some other period of the day, more or less glairy mucus, 
just as bronchitic individuals "raise" phlegm of a morning on rising. 
These old people can, or do, regurgitate this mucus, and yet retain the 
contents of the stomach perfectly well. Nausea is far from infrequent in 
these cases, but very rarely is accompanied by vomiting. 

Flatulence and heartburn are so common in many old people as to be 
regarded as the natural attendants of old age. Heartburn or cardialgia 
arises from the acid mucus which is belched up into the oesophagus. 

Flatulence is sometimes the chief sign of this condition and is always 
very distressing ; it is most annoying during or a little after the period of 
digestion, though you wall find some old people complaining of it when the 
stomach is empty. Old gourmands form the greater part of the former, 
and chronic tipplers of the latter class, for self-evident reasons. Flatulence 
is sometimes so great that the distended stomach and intestines feel 
" sore," and are painful to the touch. 

Pyrosis, "water-brash," or black water, as it is variously styled, is often 
present in old people, in women especially, as a chronic and obstinate ac- 
companiment of catarrhal dyspepsia. The fluid is thin, watery, colorless, 
and either insipid to the taste or so acrid and sour that it sets the teeth on 
edge. More or less pain precedes the gush of liquid into the mouth, 
which is followed by almost immediate relief. You will find pyrosis com- 
monest in old people who are ill-fed, poorly clothed, and who live princi- 
pally upon vegetable food, or are habitual spirit-drinkers. _ Pyrosis may 
occasionally be° so great as to amount to gastrorrhoea, a condition analogous 
to the blennorrhoea of other parts. 

Gastrodynia, more or less severe pain in the stomach, is by no means an 



244 CLINICAL LECTURES ON 

infrequent symptom of senile gastric catarrh, and it is met with as well 
when the stomach is empty as during the various periods of digestion. 

Sometimes the pain is diffused, and again it is confined to a spot no 
larger than a silver dollar ; it is relieved by pressure. ' 

The tongue is usually pale and flabby in old subjects who have long 
suffered with gastric catarrh ; often it is indented with the marks of the 
teeth. It may be studded with minute aphthous ulcers. The tongue 
in other cases has a peculiar " sodden" look, or may be perfectly normal 
even in very obstinate and prolonged cases. The breath is always offen- 
sive in these old patients. The texture and color of the skin, hair and 
nails are altered from the normal, and present a shrivelled appearance. 

Old people who have long suffered from catarrhal dyspepsia are rarely 
free from hemorrhoids ; they are also habitually constipated, intercurrent 
attacks of diarrhoea being, however, far from infrequent, and you may find 
large quantities of mucus mixed with scanty alvine dejections. 

The urine is scanty, dark-colored, sometimes depositing urates, phos- 
phates and oxalates, although it is far from ben, limentary as in 
adult life. It is often clouded, even at the time of emission. The specific 
gravity varies with the diet and the time when voided, as for instance, 
whether morning or evening. 

Finally there is a train of symptoms called u sympathetic." which occur 
late in the disease, and undoubtedly arise from the gastric disturbance. 

Hypochondriasis, despondency, mist rust of old friends, and irritability 
of temper are common in these cases ; there is either sleeplessness, or tho 
sleep is disturbed. Dyspnoea, sighing, chilly sensations about the ex:, 
ties, slight febrile reactions, preceded by rigors, slight night-sweats and an 
icteroid hue of the conjunctiva?, these are rarely absent in cases of senile 
gastric catarrh. 

Differential diagnosis. — Chronic catarrh of the stomach, or catarrhal 
dyspepsia, may be mistaken for ami I 

The points in the differential diagnosis between senile gastric catarrh 
and ammonaania will be considered under the heed 1 t Ammonamia. 

Atonic dyspepsia occurs in those whose pursuit or mental condition is 
accompanied by great depression, wh arrhaldyt iated 

with chronic cardiac, pulmonary or hepatic disease, or is induced by 
"tippling." There is no pain or tenderness over the epigastric region in 
atonic dyspepsia, while these are never absent in senile chronic gastritis. 
The tongue is pale, broad, and flabby in atonic dyspepsia, and often c» 
with a thick coating in chronic gastric catarrh. 

Anorexia and thirst are marked symptoms in senile chronic gastritis, 
while thirst is not a prominent symptom of atonic dyspepsia, and 
tite is slightly, if at all altered. 

In atonic dyspepsia there are no constitutional or sympathetic symp- 
toms, while progressive emaciation, weakness, a jaundiced, sallow, or earthy 
color to the skin, a well-marked cachectic state, and disordered mental con- 
dition, are prominent in chronic gastric catarrh. 

The alterations in the urine of chronic gastritis, which I have just given, 
are not found in atonic dyspepsia, the secretion being normal. 

Finally, the bowels are regular in atonic dyfi bile in senile 

trie catarrh they are constipated, slight attacks of diarrhoea, occurring at 
varying periods in the course of the disease. 

I shall continue this subject at my next lecture. 

1 The subject of gouty gastritis has been referred to by Professor Charcot in pre- 
vious pages of this book. 



THE DISEASES OF OLD AGE. 245 



LECTUEE XXIX. 

CHRONIC GASTRIC CATARRH. 

Summary. —Prognosis— Treatment. 

Diarrhoea in Old Age— Etiology— Symptoms— Varieties— Differential Diagnosis 
— Prognosis — Treatment. 

Constipation in Old Age — Etiology — Symptoms. 

Gentlemen :— The prognosis in the catarrhal dyspepsia of old age is 
always good ; it is rarely a direct cause of death. 

The prognosis for recovery depends on the age ; when over seventy, if 
it has existed a considerable time, it is incurable. It also depends on the 
power or will of the patient to conform to the diet and regimen prescribed, 
and finally on the causative or complicating diseases. You will, therefore' 
carefully study the thoracic and hepatic conditions of an old person with 
chronic gastric catarrh, before giving what should always be a guarded 
prognosis. 

Treatment. — All medical treatment is secondary to diet and regimen. 

Abernethy said that a man could not be induced to attend to his diges- 
tive organs till death, or the fear of death, stared him in the face. 

Indeed, in many instances a cure can be brought about by regulation 
of the diet alone, when there is no organic disease complicating the ca- 
tarrh. When complications exist, the treatment resolves itself into the re- 
moval of the cause. This effected, the disease becomes readily amenable 
to treatment. 

A diet for an old person with chronic catarrhal dyspepsia — subject of 
course to such variations as shall be indicated by the patient's idiosyncrasy 
— is the following : 

First, it must be remembered that the greatest regularity as to the 
time of meals must be preserved ; the number of the meals should be four 
or five, rather than three. Five or six hours must intervene between the 
times of taking food, to give the stomach its needed repose, and the pop- 
ular error of thinking that, as age advances, the quantity of food must be 
increased, should always be avoided, for excess in old age means disease. 

On rising, the patient should always take a glass of fresh milk, contain- 
ing either soda- or lime-water ; and when the strength and age do not 
contraindicate, a " rub-down " with a coarse towel will be found to have a 
wonderfully refreshing effect, and the relation between a brisk feeling of 
well-being and the appetite is too well known to need comment. 

At breakfast the aged patient may have weak tea or milk, fresh eggs 
lightly cooked, a chop not too well done, stale bread with but little butter. 

Luncheon may consist of oysters, or, when no meat has been taken at 
breakfast, of a chop or piece of mutton, a glass of old sherry, with perhaps 
an egg in it, and yesterday's bread. 

Or the luncheon may be some fresh broth, a sandwich of grated fowl, a 
glass of sherry or bitter ale, and bread. 



246 CLINICAL LECTURES ON 

If any fruit is taken, it must be either at breakfast or luncheon. ' 

Dinner should be made of fresh, light fish, mutton, game, tripe, or 
underdone beef, floury potatoes, light vegetables, and a glass of sherry or 
claret ; or, when it is indicated, a little brandy arid soda-water. 

Before retiring, a dry biscuit with milk and arrow-root, or a little brandy 
may be taken. All the food is to be thoroughly masticated, and eaten very 
slowly. 

A few words as to what must be avoided in the diet of the aged. 

Too much liquid at meals is injurious ; for it dilutes the gastric juice, 
impedes digestion, and, if excessive, relaxes the stomach. 

Tea, coffee, cocoa, and milk may be taken in moderate quantities with 
benefit, but are least objectionable an hour after meals. 

Broths containing vegetables are extremely indigestible in the stomachs 
of the aged, and butter and cheese must be rare articles of diet. 

Over-done, well-done meat, fresh bread, cabbage, carrots, turnips, veal, 
lamb, pork, salt meats, pastry and salads, are to be forbidden in the senile 
period of life. Bemeinber Watson's saying : " Gout in the stomach should 
be oftener called pork in the stomach." 

Shell-fish, lobsters and crabs, and salmon, herring, eels, mackerel and 
other kinds of rich, oily fish, must be avoided, for they often excite attacks 
of acute dyspepsia, whose gravity is out of all proportion, apparently, to the 
amount of the article taken. 

Fermented liquors and oatmeal very frequently occasion flatulence and 
acidity of the stomach, so their use must be determined by the effects 
produced in each individual's case. 

Variety is necessar . but it should never be at the expense of sim- 
plicity and wholesonieiKss of the food. 

Next in importance to the diet, in the management of senile gastric 
catarrh, is the condition of the bowels. 

The relief experienced after free alvine discharges is often so great, that 
the aged patient refers most of his troublesome symptoms to the consti- 
pated state of his bowels. 

An aloetic pill may be taken regularly at dinner ; and Hunjadi Janos 
or Friedrichshall are excellent laxative mineral waters. 

Bhubarb and soda, or rhubarb and strychnia, are also efficient remedies 
for the chronic constipation attending senile gastric catarrh. The bowels 
must be kept regular, and hence the patient should go to stool at some 
stated time each day, whether desire is felt or not. 

Exercise in the fresh air, cleanliness, early retiring and rising, and warm 
clothing, cannot be overrated as adjuvants to the treatment of catarrhal dys- 
pepsia. A dry climate often produces markedly beneficial results. 

Anorexia in old age is best treated with aromatic bitter infusions : quas- 
sia, columba, gentian and Peruvian bark, combined with strychnia, quinine 
and iron ; and in the morbid sensibility of the stomach of old dram-drinkers, 
opium in small quantities will in many instances relieve the anorexia. 

For the relief of the flatulence, the diet should be essentially dry. 
Vegetables should form but a very slight part of the food taken. Fari- 
naceous food, potatoes especially, seems to disagree with this class of 
patients, while spices and the alkalies are often partaken of with bene- 
fit. 

Cajeput oil, creosote, sulphite of soda, charcoal, and a combination of 
ammonia and the compound tincture of sulphuric ether, rarely fail to give 
at least temporary relief. 

Cardialgiaj or heartburn from acidity, is to be combated by the ad- 



THE DISEASES OF OLD AGE. 247 

ministration of alkalies. Magnesia, potash and soda are much used, but 
lime-water in milk acts best, and gives more permanent relief. 

Minute doses of morphine can be given when hyperacidity causes ex- 
treme irritation of the stomach ; and bismuth with the bitter infusions also 
acts beneficially in allaying gastric irritability. 

In pyrosis much benefit is often obtained by a change in the diet. 
Minute doses of morphia, with bismuth and bicarbonate of soda, in com- 
bination, may be given in extreme cases. 

I have used kino, conium and belladonna with marked benefit in some 
cases. 

For the relief of gastrodynia, nitrate or oxide of silver, with iron and 
rhubarb, has been highly recommended ; but by far the most efficacious 
drug for its relief is the subnitrate of bismuth, which may be given in 
doses varying from five to twenty grains, three times a day, for an indefi- 
nite period. Hydrocyanic acid is a remedy that sometimes acts when all 
others fail, but it must be used with great care. When an attack of acute 
gastrodynia plainly arises from an overloaded stomach, an emetic of warm 
water may be given. 

Hepatic, cardiac and pulmonary causes are to be treated according to 
the rules elsewhere given for their management ; anaemia is to be com- 
bated with iron in the form of chalybeate waters. 

If the gastric juice appears to be deficient in amount, pepsin and hydro- 
chloric acid are to be given with the two principal meals of the day. 

When, in old age, the dyspepsia is of nervous orgin, preparations of 
zinc, arsenic and phosphorus are useful ; and a " little wine for the stomach's 
sake " often enables that organ to act more efficiently. 



DlARRHCEA IN OLD Age. 

I shall briefly, in this connection, call your attention to a very frequent 
condition in advanced life. viz. : diarrhoea. 

Just here it may be said that, when the trouble is of catarrhal origin, the 
pathological changes and morbid appearances differ in nowise from those 
of adult life ; but a much milder and less extensive catarrh will induce 
serious symptoms than in middle life or childhood. 

Etiology. — This condition is more frequent in those who grow old 
rapidly, and in many cases seems to arise from a state of the intestinal tract 
that is part of the senile marasmus ; indeed, the name " senile lientery " has 
been given to one variety, so common is it at this period of life. 

Epidemics of diarrhoea are not infrequently met with when large num- 
bers of old people are crowded together in asylums and hospitals. 

Errors in diet are prominent causes of senile diarrhoea. 

Exposure to cold, sudden chilling of the body, and abruptly checking 
the perspiration are common causes of diarrhoea in the aged. 

Aged gouty subjects have frequently a peculiar form of diarrhoea, 
which is intermittent and seems to be a sort of safety-valve, as great relief 
often follows slight attacks. 

Diarrhoea is more prevalent in the winter than in the summer months. 

I do not speak of the diarrhoea which, in the senile period of life, so 
frequently accompanies hepatic, renal, thoracic and various other chronic 
affections, and to which the name of symptomatic diarrhoea has not im- 
properly been given. 

Symptoms.— 11 Senile lientery " is the commonest form of diarrhoea m the 



248 CLINICAL LECTUEES ON 

aged, and its most usual cause is over-feeding. You will very often find 
that many perfectly healthy old people have from four to six movements 
of the bowels each day, and that this condition has not only persisted 
for a long time, but it is also unaccompanied by any unpleasant symptom ; 
indeed, some continue to grow stouter while the diarrhoea continues. 

In this habitually relaxed state of the bowels, the stools are always pul- 
taceous. 

This feculent diarrhoea is most marked in those corpulent and sedentary 
old people whose appetite is undiminished with age, while their stomach 
and intestines are incapable of their former vigorous action. 

When a diarrhoea coming on in old age is marked by limpid or brown- 
ish liquid discharges, it is called 9STOU8 ; it may be serous diarrhoea from 
the very onset, or it may be the result of neglect or improperly treated 
senile lientery. 

In serous diarrhoea the normal faeces are first swept out by the early dis- 
charges, after which the motions consist of thin, ochry fluid, always offensive, 
and often frothy. 

You will find that this form of diarrhoea almost always is the result of 
exposure to cold and wet ; and at the commencement there may be some 
slight febrile movement, attended with rigors. 

When partial or complete retention of the contents of the lower bowel 
accompanies a serous flux, the motions are scybalous, and the efforts to 
expel these hardened masses are constant and painful 

Catarrhal diarrhoea, or the mucous flux, differ in no way from the 
intestinal catarrh I have elsewhere spoken of, and is quite rare in old age. 

Bilious dejections are usually attended with considerable exhaustion in 
old age. The tongue becomes furred, the complexion sallow ; there is head- 
ache, and there may be a feeling of weight and uneasiness in the right 
hypochondrium. 

When they continue even for a short time, the face becomes drawn and 
haggard, the eyes seem sunken, the pulse is weak and compressible ; the 
temperature falls sometimes below the normal standard, and the patient 
dies in a short time from exhaustion. 

It is to be borne in mind that, in advanced life, an acute diarrhoea may 
steadily persist while the patient utters no complaint, shows no signs of 
distress, and still the disease may be rapidly tending to a fatal issue. 
Griping and tenesmus are symptoms which are much oftener absent than 
present in senile diarrhoea. 

Differential diagnosis. — This condition is not likely to be confounded 
with any other ; but a diarrhoea may turn you away from a dangerous 
causative state, such as cancerous disease of the rectum or fecal accumula- 
tions in the rectum and colon. 

A digital examination of the rectum will generally determine at once 
the latter condition. 

Prognosis. — Diarrhoea is never without danger in old age. The outlook- 
is worse the longer it continues, the more obstinate it is. and the graver its 
cause, as, for example, it is more serious when associated with cancer or 
ulceration of the rectum, than when it depends upon simple impaction or 
an indiscretion in diet. 

Old age diarrhoea is frequently an attendant of hemorrhoids, and one of 
its commonest sequelae is constipation. Death is caused by exhaustion. 

Treatment. — When an old person has been over-indulgent at table, the 
plainest indication is to rid the intestine of the offensive material, and 
therefore such a laxative as castor-oil is to be employed. 



THE DISEASES OF OLD AGE. 249 

Saline purgatives should be avoided, for in advanced life great exhaus- 
tion is frequently the result of a few rapidly induced watery evacuations. 
Hence it is always advisable to combine rhubarb, or its compound tincture, 
with the drug we administer ; and if there is flatulence, half a dozen drops 
of laudanum may be advantageously added. In weak, aged patients, rhu- 
barb, magnesia, and opium will be found to act remarkably well. 

When the patient gives a history of a diarrhoea that has continued for 
some time, so that the bowels may be safely regarded as freely emptied, 
Dover's powder, combined with some such astringent as krameria or cate- 
chu, will be found to check it with great promptness. Chalk-mixture, 
combined with chloric ether and tincture of opium, is also valuable in 
similar instances. 

When there is a marked febrile movement, Dover's powder is of the 
greatest value, and, in cases where prostration is not excessive, it may be 
combined with mercury and chalk. 

Wlien the case remains obstinate, and all these remedies have been 
tried, then you must resort to kino, catechu, logwood, tannic and gallic 
acids — the vegetable astringents — combined with opium. 

Finally, the metallic astringents, copper, lead, silver, and iron, may be 
cautiously employed. 

When senile diarrhoea is associated with a condition of anaemia, the 
mistura ferri compositus is of great utility, but, perhaps, the best com- 
bination under such circumstances is that used in those English hospitals 
where the inmates are mostly far advanced in life, namely, half a grain of 
cupric sulphate and a grain of opium twice a day, gradually increasing the 
dose of the former to three grains. The most rebellious forms succumb 
to this treatment. 

When the urgent symptoms have passed, the dilute mineral acids, ni- 
tric and sulphuric, act beneficially, by first checking fermentative action, and 
then toning up the relaxed mucous membrane. 

Suppositories are to be employed when there is much tenesmus, and 
when either an enema is inadmissible, or it is impossible to administer 
medicine by the mouth. Should there be any palpable cause which can bo 
removed, the primary indication is, of course, to remove it. 

Warmth is very efficacious, and often aids materially in checking a sim- 
ple flux. An old writer, Wainwright, said : " A woollen shirt mightily con- 
duces to cure an habitual diarrhoea." Warm flannels should be continu- 
ally replaced over the abdomen ; and in severe cases recourse may be had 
to warm poultices or hot fomentations. 

The food should be of the most non-irritating character ; alimentation 
must be chiefly amylaceous; and sago, rice, arrow-root, etc., in milk, are 
best borne. In some cases, wine with this diet seems to aid in checking 
the diarrhoea ; and if the aged patient have been accustomed to wine for a 
number of years, it is not advisable to stop its administration. 

Other stimulants must be avoided, as well as rich and highly seasoned 
food. It is best that, for a time, all meats should be avoided. It is im- 
perative that an old person with any form of diarrhoea should have absolute 
rest in bed, and should avoid any sudden movement or mental excitement. 

The recumbent posture prevents gravitation, and hence the rapid pas- 
sage of the fluids over the irritated membrane. 

A dry, stimulating atmosphere is the best for aged patients who suffer 
from diarrhoea ; and if the diarrhoea can clearly be ascribed to a malarial 
cause, large doses of quinine, are indicated. 

When the principal pathological changes are in the rectum, much benefit 



250 CLINICAL LECTURES ON 

will be derived from starch, enemata combined with opium or biborate of 
soda ; rest and warmth, a simple diet, and a dry, bracing air will often- 
times effect what medicine cannot. Hence, hygienic treatment is of the 
first importance in senile lientery. 

Next to the diarrhoea of old age comes properly the consideration of 
constipation. 



Constipation in Old Age. 

Habitual constipation is far more frequent in the aged than in adult life. 

Etiology. — In most instances habitual constipation in the aged arises 
from loss of power to propel the contents of the intestine onward, and 
also from a diminution in the sensibility of the lower bowel. It may be 
caused by diseases of the brain and spinal cord ; senile dementia, atrophy, 
softening, and hemiplegia are always accompanied by constipation. 

The abuse of purgatives leads to chronic constipation, and constipation 
is often one of the results of long-continued senile lientery. The use of 
opium favors constipation. Collections of impacted fa?ces in the rectum 
have sometimes been found to surround masses of pills and other sub- 
stances, such as magnesia, which were given to relieve constipation. 

Change of diet, scene, or habit, anything interfering with the regular 
act of defecation, may cause temporary constipation, and this, in ol< 
is very apt to become habitual. Diminished contractile power of the ab- 
dominal muscles, the result of excessive development of fat, is a frequent 
cause of constipation in old age. 

It ma}' also result from unnatural dryness of the fceces, such, for exam- 
ple, as occurs in diabetes, where a very large quantity of lluid is carried off 
by the kidneys. 

Torpor of the rectum, which may either be primary or follow prolonged 
inactivity of the upper portions of the large intestine, is a cause peculiar to 
the constipation of old age ; and it is rare not to find it in feeble, infinn, 
bed-ridden patients, women especially ; indeed, women suffer much oftener 
from this condition than men. 

Constipation occurs more often in the sedentary and sluggish, where 
the calls of nature are neglected or postponed, in those who allow 
fecal masses to accumulate in the intestine, and thus diminish its sensi- 
bility. In such case the constipation may be purely the result of habit, and 
hence have no other assignable cause. 

Symptoms. — The aged submit to temporary constipation with indiffer- 
ence, a blunted sensibility of the intestinal canal favoring this. With the 
listlessness of advancing years, the dangerous habit of deferring to answer 
the call of nature leads to habitual constipation. 

What may be regarded as constipation in one person is regularity in 
another. Thus, cases are on record where, from boyhood until the seven- 
tieth year, the bowels did not move more than once a week, and yet the in- 
dividual enjoyed excellent health. Such individuals do not bear purging, 
and it is not safe to administer drastic cathartics to them. 

In those accustomed to take large quantities of opium, the bowels have 
been known to move only four times in the year. The history of each 
individual will tell you if the bowels are sluggish, and whether t . 
to be regarded as one of constipation. 

When, in an old person with regular habits, two or U a - peas 

without defecation, there is a sense of local fulness and hi 



THE DISEASES OF OLD AGE. 251 

to piles and flatulence, headache, vertigo, foul breath, anorexia, and well- 
marked dyspeptic symptoms. The patient is frequently hypochondriacal. 
If a predisposition to apoplexy exists, obstinate constipation often hastens 
tha apoplectic stroke. 

If a condition of constipation persists, vertigo becomes frequent, there 
are ruuscae volitantes, tinnitus aurium, spasms of dyspnoea, sleeplessness, 
and occasionally a dull, steady, frontal headache ; the skin becomes parched, 
shrivelled, and sallow, and is liable to various kinds of eruptions, especially 
psoriasis, eczema, prurigo, erythema, and erysipelas. Injuries heal very 
slowly. The tongue is flaccid, and often indented by the teeth. The kid- 
ney and liver secrete morbid products, or the excrementitious bile being 
retained in the blood, it is rendered more or less impure. The ilio-hypo- 
gastric and ilio-inguinal nerves may be pressed on by the distended caecum 
and adjoining colon, and neuralgic pains in the groin or over the iliac crest 
may result. 

Hemorrhoids and flatulence are now marked ; there is more or less un- 
easiness in the genito-urinary tract because of the pressure from the tumor 
of indurated faeces, which likewise cause the piles and flatus. The veins 
of the lower extremity, testicle or ovary, may be pressed upon, and oedema 
of the feet and varicose veins occur. In prolonged cases the action of the 
stomach is crippled, and in many cases a cachexia is developed. 

I shall continue this subject at my next lecture. 



252 CLINICAL LECTUIiES ON 



LECTURE XXX. 

SENILE CONSTIPATION. 

Su mmary.— Constipation in Old Age {continued) — Symptoms — Differential Diagnosis 
— Prognosis — Treatment. 

Changes in the Bladder and Urine in Old Age — Atony or Paralysis of the Blad- 
der — Definition — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treat- 
ment — Chronic Enlargement — Hypertrophy of the Prostate Gland — Morbid An- 
atomy — Etiology. 

Gentlemen : — Constipation is felt most from its results. Dilatation and 
hypertrophy of the intestine are very common conditions in old age. The 
dilatation begins just above the rectum, extends upward the entire I 
of the large intestine, the circumference in the latter intestine may m< 
from nine to twelve inches. Hypertrophy of the intestinal walls usually 
attends this dilation, and is best marked in the rectum and sigmoid flexure. 

Pouches may form in the colon ; and an elongated sac tilled with n. 
or faeces forms a sort of hernial protrusion as the circular muscular fibres 
yield. These pouches are most common at the sigmoid flexure. 

"Ulcerations may arise from prolonged constipation ; perforation of the 
weakened wall and extravasation of the contents may lead to fatal peritoni- 
tis. Typhlitis and perityphlitis may arise from it. The colon and sigmoid 
flexure are altered in their position as well as in shape, their curvature > 
becoming more sharp than normal. 

Disease of the rectum and contiguous structure turia me*, 

abscesses about the rectum, fistula, anal Assures, stricture, prola] 
of the prostate gland and the bladder, passive hypera inia of the pelvic vis- 
cera, all are frequently met with in advanced life, and are in most instances 
clearly assignable to fecal accumulations, the result of habitual torpor of the 
bowels. 

With torpor of the rectum, there is sometimes a spurious diarrl 
acconrpanied by acute pain in the lower pari of the abdomen, by 
tenesmus and "bearing down" during defecation, and by the prefi 
Bcybalee in the foecea It may be accompanied by dysuria and even reten- 
tion. Heus and strangulated hernia have resulted from neglect of thi 
por, which maybe so complete that the relaxed and distended rectum, filled 
with hard f;eces, occupies nearly the whole pelvic cavil 

The accumulated faeces frequently form tumors at different points along 
the digestive tract, and in emaciated subjects are easily detected on | 
tion. They are often felt in the transverse or ascending colon as movable 
masses ; but the largest accumulations collect in the sigmoid riVxui 
caecum, where manual palpation in the left or right ileo-inguiual i\ 
readily discovers their size and sometimes their consistence. 

Differential diagnosis. — The differential diagnosis between spurious diar- 
rhoea (torpor of the rectum) and senile lientery I have already coi 

Prognosis. — You will have observed that, in the consideration of senile 



THE DISEASES OF OLD AGE. 253 

constipation, all malignant growths, all mechanical interferences other than 
fecal, have been disregarded ; for when such are the causes, constipation is 
only a secondary symptom of a graver condition. 

Hence, if we regard constipation as a retention of fasces in -the lower 
part of the large intestine, the prognosis is very favorable, provided we 
can overcome the apathy and habitual indolence of the aged patient. 

Inflammatory complications are very grave ; fortunately, however, they 
are rare in the aged. Peritonitis, if it occurs, is always fatal. 

Treatment. — An old person should go to the water-closet at the same 
time every day, whether he has the inclination or not. The slightest call 
of nature must never be disregarded. 

Friction over the abdomen, or when the aged patient is confined to a 
chair, or is much debilitated, bending the body backward and forward will 
be found to provoke and aid defecation. 

The galvanic current over the abdomen, along the course of the large 
intestine, and to the anus, acts beneficially in many cases — the rationale 
of its action being the same as that of friction, rubbing, and kneading of the 
bowels. 

The diet should consist largely of vegetables, unless they are contrain- 
dicated. Prunes and figs are excellent gentle laxatives in the aged. 

Oatmeal, when it does not excite flatulence and heartburn, may be 
taken every morning with molasses instead of milk. A goblet of fresh 
cold water just before retiring or on rising will, in many cases, relieve a 
sluggish condition of the bowels, and a cigar or pipe after meals often has 
the same effect. But in many cases vegetables, oatmeal, fruit, smoking, 
all disagree with the patient, or are not efficacious, and then recourse must 
be had to medicinal agents. 

Many old people have taken first gentle, then stronger, and finally the 
most powerful aperients, with the belief that the bowels must move every 
day. In such cases you should call diet and exercise to your aid, and 
return to the milder laxatives, endeavoring to produce a healthy evacuation 
every other day. Tonics should always be combined with the laxatives ; 
indeed, many have gone so far as to regard strychnia, iron, or quinine, 
when given alone, as able to effect a radical cure in most cases. 

Colocynth, gentian, and quinine, is an excellent combination for a pill 
in mild cases. So also is a pill composed of aloes, rhubarb, and strychnia, 
or iron. Another efficient combination is aloes, myrrh, and gentian, com- 
bined with quinine, strychnia, or iron. 

Podophyllin often produces slow and painless evacuations, and deserves 
a careful trial in the treatment of senile constipation. 

In very obstinate cases the treatment may begin with the exhibition of 
the compound extract of colocynth, scammony, and about the sixth of a 
drop of croton-oil. One or two of such pills may be taken before dinner 
or at bedtime. 

These may be continued for a long time. Maclachlan records a case 
of a lady one hundred and three years old, who for the last fifty years of 
her life took a compound aloetic or rhubarb pill at bedtime. Brodie 
speaks of a gentleman, eightv-six years of age, "who for three-score years 
took an aloetic pill every night." The general rule in advanced life should 
be to use only mild laxatives, and to change them frequently ; the contin- 
ued use of drastic purges in old age is apt to lead to trouble. 

When colonic or caecal accumulations occur, active purgation is neces- 
sary ; at the same time the aged patient must be sustained by stimulants 
and nutritious food. 



254 CLINICAL LECTURES ON 

When the lower part of the bowel is clogged, the mass will often have 
to be scooped out ; and, when very hard, this operation is best preceded 
by a steady stream of moderately hot water against the mass for about 
half an hour. 

Purgative enemata should be adjuvants to all forms of treatment, look- 
ing to the expulsion of a large mass that has been accumulating for a long 
period. 

A case is recorded in the " Cyclopaedia of Practical Medicine," of an old 
gentleman — paraplegic — who had a gallon of salt water thrown up every 
morning for a week after constipation of long duration. After several 
days an enormous mass of fasces passed, the activity of the muscular fibres 
having finally been called into play. 

I shall now briefly invite your attention to diseases of the bladder ; as 
we meet them in the aged, they are very different from those of adult life. 



Atony or Paralysis of the Bladder. 

Vesical paresis is frequently met with in the aged of both sexes ; it is 
essentially a condition of advanced age. 

In accordance with the plan I have adopted, a few words are nect 1 
in regard to the changes which are normal to old age, and, at the 
time, different from those of adult life. 

Healthy old people secrete less urine than in middle life, and the color 
of the fluid is paler, less rich in solid constituents, and of lower specific 
gravity than normal adult urine. Epithelium from the various portions of 
the genito-urinary tract and mucus are usually quite abundantly mingled 
with it. 

The amount of urea secreted by very old men is small — only one hun- 
dred and twenty-five grains in twenty-four hours, being noticeaK 
than the amount in the urine of young children. The amount of uric acid 
is also diminished by about one-half. 

The quantity of urine discharged in old age averages sometimes as low 
as fifteen or twenty ounces per diem, and this is compatible with perfect 
(senile) good health ; but, when not more than six or eight are voided, the 
system soon indicates the presence of an abnormal quantity of urea. 

By atony or rmresis of the bladder is understood a lack of power in 
its muscular coat, by which its longitudinal and oblique muscular fibres 
and the detrusor urinaj do not contract, or only do so in a very tard; 
imperfect manner. 

Etiology. — In a limited sense, atony of the bladder is physiological in 
old age ; it is well known that the distance to which a boy can throw a 
stream of urine from his bladder is greater than that of an older person, 
and so the power of expelling the secretion goes on diminishing with ad- 
vancing years. 

There are two reasons for this : one is, that there is a steady loss of 
muscular power, a senile decay throughout the entire muscular system, 
the muscles losing their normal contractility ; and the other is, that the 
older the person, the more engaged in business care-; he will be, and hence, 
the calls of nature to void the bladder are very frequently and habitually 
unanswered. Thus, there is a certain degree of habitual distention of the 
bladder, not only during the day, but at night as well. 

This disregard to empty the bladder may be, as I have just said, voluu- 



THE DISEASES OF OLD AGE. 255 

tary. Involuntary neglect occurs in prolonged alcoholic intoxication, and 
in all those diseases, whether acute or chronic, which affect the sensorium 
— among these may be mentioned small-pox, typhoid, typhus, paraplegia, 
apoplexy, epilepsy, and diseases of the spinal cord. 

Paralytic weakness of the bladder in old men is very frequently second- 
ary to an enlarged prostate ; and it may result, in either sex, from the 
individual being compelled to remain in a recumbent position a long time. 

Senile catarrh of the bladder may lead to subsequent paresis, from im- 
plication of the muscular coats in the process. 

Women who have had large families, and whose labors have been se- 
vere, are especially prone to palsy of the neck of the bladder ; the obese 
suffer oftener than those of the opposite condition. 

Paresis of the bladder, though common to both sexes, is more frequent 
in men from prostatic enlargement ; there seems, too, to be a predisposi- 
tion in some to atony of the bladder, and in them you will find such causes 
as passing from a heated room to the open air, or the slightest over-indul- 
gence at table, sufficient to induce temporary attacks of retention of urine. 

Finally the more impaired the general health, and the more sedentary 
the life of the individual, the greater the predisposition to atony of the 
bladder. 

Symptoms. — The bladder, unlike the rectum, retains its contents when 
paralyzed ; for the elasticity of the sphincter vesicae is inherent in the tis- 
sue itself. Thus retention occurs ; or, if the sphincter be involved also, we 
have a combination of incontinence and retention ; paradoxical as it may 
appear, only a part of the urine passes off, and that by its own gravity, 
aided, perhaps, somewhat by the action of the abdominal muscles, after a 
considerable quantity has accumulated in the bladder. 

The aged patient notices that there is a gradual diminution in the 
power of emptying the bladder ; that, after he wills to micturate, quite a 
time elapses before the first drops come, and that the act is more prolonged 
than usual, the urine falling perpendicularly and only becoming a full stream 
at about the middle of the act. 

The desire to micturate is now less often felt ; and if, when felt, it is 
disregarded, the desire soon disappears, as if the bladder had been 
emptied. 

The stream is feeble and interrupted ; occasionally the urine flows 
away either in drops or interruptedly, and the odor is usually disagree- 
able on account of its ammoniacal decomposition. 

This latter condition is generally the accompaniment of a paralyzed 
sphincter with vesical atony. 

After the patient thinks the act of urination is complete, a few drops 
will suddenly pass ; not infrequently those in advanced life have an escape 
of urine during the night. 

When the bladder has once become greatly distended, a considerable 
quantity of urine continues to dribble from it, the retention being still 
unrelieved. 

This retention with dribbling in old persons is a condition the true 
nature of which is frequently unrecognized. Cases have arisen where 
supposed tumors have been tapped, and a distended bladder entered, and 
a large amount of retained urine drawn off which was never suspected. 

In the very old the urine may steal away from the bladder as it flows 
drop by drop from the ureters. 

When retention is excessive the bladder slowly enlarges, finally rising 
up into the abdomen even as high as the umbilicus. 



256 CLINICAL LECTURES ON 

On palpation, the distended bladder is felt round or pyriform in shape, 
hard, and elastic, projecting above the pubis ; over it you may detect fluc- 
tuation through the abdominal walls. 

Percussion elicits well-marked dulness, varying in extent with the 
amount of distention. 

If a condition which gives these physical signs is not relieved by the 
catheter, the aged patient will either have true incontinence following, the 
urine flowing away uninterruptedly; or there may develop urceniia, ammo- 
ncemia, intense catarrh of the bladder, or even vesical gangrene. 

In all cases the true condition of the bladder is readily determined by 
the introduction of the catheter ; and, in those advanced in life, and espe- 
cially when occupying a recumbent position, it may be necessary to press 
the hand over the bladder in order to expel the urine. 

Differential diagnosis. — Atony of the bladder in old age may be con- 
founded with retention from obstruction, and with ascites. 

In atony the urine will flow out slowly, or in faintly marked jets, in obe- 
dience to the respiratory acts, when the catheter is introduced, oftentimes 
pressure from without being necessary to expel it. In retention from ob- 
struction, the introduction of the catheter is attended with more or less 
difficulty at some point ; but, having once entered the bladder, a free 
stream is projected in a single jet. 

Ascites lias misled many from atonic retention, and some have tai 
the abdomen for dropsy. The introduction of the catheter is an unfailing 
means of diagnosis. 

Prognosis. — The results of not attending to atonic retention are various 
and grave. 

The constituents of the retained urine becoming absorbed, and the skin 
thus being charged with the extra duty of elimination of part of them, 
chronic eczema or some other form of intractable entail 'lion may 

occur, only to yield when the bladder is freed from all residual mine. 

Vesical catarrh, animonamia. anemia, and gangrene or sloughing of the 
bladder, are the complicating conditions which may ensue when tL 
has been of long standing. 

Complete recovery rarely occurs in these cases. The worst cases are 
those where paralysis and over-distent ion of the bladder have existed along 
time. In most of these case s. even when the bladder is regular 1 .; 
the patient is only relieved, not cured, tin b con- 

tinues, and, finally, comparatively rapid dissolution results. 

The prognosis becomes unfavorable when the patient has a rapid and 
feeble pulse, a furred tongue; when the appetite fails and the nigl. 
restless ; mental depression and final stupor supervenes. 

Death commonly occurs, in such cases, from exhaustion or urremia. 

Finally, the prognosis is influenced in a great measure by the age of 
the patient and the extent and duration of the atony. 

Treatment. — Old people cannot have it too thoroughly im] ipon 

them to empty the bladder directly the call of nature is felt. Thi- 
most important prophylactic measure. 

If the patient be an old invalid, he must assume a position on the knees 
when micturating, for otherwise the bladder is incompletely emptn 

Petit has recommended that in simple atony the patient should | 
the cold chamber firmly against the thighs and scrotum : or cold lotions, 
cold hip-baths and cold sponging may be resorted to. 

The catheter must be passed three or four times daily, so as : 
the muscular libres from any further distention. But do not \ 



THE DISEASES OF OLD AGE. 257 

theterization so often that little urine shall collect in the bladder and in 
tins way convert the organ into a mere passage. The patient should learn 
to pass the instrument himself. 

If injections into the bladder are resorted to, the amount of fluid iniec- 
tions must not be more than four ounces at a time, and the temperature 
should be gradually lowered ; thus, the first injection should have a tem- 
perature of about ninety-four or ninety-five degrees Fahr., the second 
ninety degrees, and the third and last eighty-five degrees Fahr. If vesical 
catarrh exist, never inject an old person's bladder with cold water. 

Galvanic and electric currents are often of temporary service in senile 
atony of the bladder ; the powerful internal remedies that have been tried 
and found to act beneficially in certain cases, are strychnia, cantharides 
creosote, turpentine, and ergot. 

The general health of the patient should be carefully attended to ; for, 
without nutrition at a high standard, we cannot expect the muscular sys- 
tem, and this muscle as part of it, to regain, or at least to improve in its 
power. 

Hence, in most cases, iron, strychnia, the vegetable tonics and quinine, 
form a very important part of the treatment ; the bowels must be regulated 
with aloetic pills ; indeed, some claim that direct and permanent benefit fol- 
lows the use of aloes. 

Balsams, which are highly recommended, derange the already weak di- 
gestion of old age, and vesicants and embrocations possess little or no 
advantage. The urine may be made alkaline in some cases to prevent cys- 
titis, when this threatens. 

Finally, if there be constant dribbling, a portable urinal should be af- 
fixed, and the most scrupulous cleanliness enjoined. Of all the preparations 
of iron, the muriated tincture is the most serviceable. 

Closely connected with vesical paresis is 

Chronic Enlargement, Hypertrophy of the Prostate Gland. 

I use the term "chronic" enlargement to distinguish senile prostatic 
enlargement from that which may occur in adult life from inflammation. 

Enlargement of the prostate gland is by some regarded as a physiologi- 
cal condition in old age, while others state that it is a diseased condition 
incident chiefly to, but not wholly caused by old age. 

Morbid anatomy. — Prostatic hypertrophy may be general or partial, and 
is almost entirely confined to its muscular tissue, although the glandular 
substance may be slightly involved. Pathologically, this condition of the 
gland may be classed among myomata of the prostate ; when the glandular 
structure is implicated the name adeno-myoma is applicable. 

Cases are recorded where in very old men the gland had acquired the 
size of the two fists, or even that of a child's head, nearly filling the lower 
basin of the pelvis. But, when it reaches the size of an orange, it may be 
regarded as exceptionally large, as it is generally about the size of a hen's 

egg- 

The color, externally, is unaltered. The so-called third lobe is fre- 
quently involved, and may acquire the size of a hickory-nut the remaining 
portion of the gland being unimplicated; this is called median centric hyper- 
trophy. When lateral hypertrophy exists, it is rare to find one lobe affected 
to the exclusion of its fellow. 

The tumor in general hypertrophy may be smooth, rounded, and regu- 
17 " 



258 CLINICAL LECTURES ON 

lar, but it is rather the rule for unsymmetrical enlargements to be present, 
the gland presenting great irregularity of outline. Cases are recorded 
where it has weighed twenty ounces. 

On section the cut surface pushes up above the level of the cut, and the 
alternations in color are more strikingly marked than in adult life. A 
viscid fluid, the thickened prostatic secretion, sometimes fills the acini and 
may be mistaken for pus. In many cases there is no fluid whatever in the 
gland. 

In the centre of the mass you will frequently find numerous small, 
dense fibrous tumors, rarely exceeding the size of a pea. Prostatic con- 
cretions or calculi are also very frequent accompaniments of this condition, 
and are found in the interior of the glandular acini or ducts. These are 
round, colorless masses, varying in size from <> 1 <6 of an inch to ^V of an 
inch in diameter, and resembling colloid material in their action with tinc- 
ture of iodine and sulphuric acid. Larger calculi are sometimes found in 
hypertrophied prostates, consisting of lamina? of oxalate or phosphate of 
lime, very difficult to crush. 

In some instances, pedunculated hypertrophic prostates are found, 
which surround the neck of the bladder like a collar. 

The veins of the gland are found dilated and tortuous. 
The urethral canal is in nearly all cases more or less implicated. When 
lateral hypertrophy predominates, it is twisted ; and when the middle lobe 
is chiefly enlarged, it is flattened and compressed. 

The prostatic portion of the canal is always elongated and expanded, 
so that it may become capable of holding two or three ounces of urine. 
This elongation also carries the neck of the bladder upward and behind 
the pubes. 

Etiology. — Old age is an essential condition for prostatic enlargement. 
Its exact etiological relationship with aortic insufficiency, or with chronic 
pulmonary affections, is not yet definitely determined. 

The condition is rare before fifty, and quite an exceptional circum- 
stance before sixty ; subsequently it is of quite frequent occurrence. 

Sir Benjamin Brodie used to say : " When the hair becomes gray and 
scanty, when specks of earthy matter begin to be deposited in the tunics 
of the arteries, and when a white zone is formed at the margin of the 
cornea, at this period the prostate gland usually, I might say, perhaps, in- 
variably, becomes increased in size." 

Sir Astley Cooper even went so far as to regard hypertrophy of the | 
tate as a salutary process, since " it prevents incontinence of urine, which in 
the aged would almost always take place were it not for this preventive." 

Sedentary habits, over-indulgence in venery, the contrary state of affairs, 
gout, high living, hard riding (as in cavalrymen), all these have been 
signed as causative conditions for an enlarged prostate, but 1. :orv 

proof exists to substantiate the assertions. 

One peculiar point, which it may not be out of place to mention, is that 
organic stricture of the urethra and enlarged prostate are among the rarest 
coincidences of advanced life. 



THE DISEASES OF OLD AGE. 259 



LECTURE XXXI. 

SENILE HYPERTROPHY OF THE PROSTATE GLAND. 

Summary. —Symptoms— Differential Diagnosis— Prognosis— Treatment. 

Ammonsemia— Definition— Morbid Anatomy— Etiology— Symptoms— Differen- 
tial Diagnosis — Prognosis — Treatment. 

Gentlemen :— At my last lecture I spoke of the etiology of senile en- 
largement of the prostate gland ; we shall now turn to a consideration of 
its symptoms. 

Symptoms. — Prostatic enlargement may exist for a long time to a limited 
extent without producing any symptoms that direct attention to the genito- 
urinary tract. A case is recorded where, at the autopsy of a man who 
died of old age at one hundred and one, the organs were all normal (at the 
senile standard), except the prostate, which was exceedingly hypertrophied, 
and no symptom of its presence existed during life. 

If this condition induce a "bar at the neck of the bladder," there may 
be retention of urine ; there is always in such a condition more or less 
residual urine in the bladder. 

The increased mucous secretion from the hyperaemic part, mingling with 
the stagnant urine, aids greatly in its decomposition ; and the carbonate of 
ammonia thus set free increases the inflammation and induces retention, 
and thus distention of the bladder is a constant result of an enlarged pros- 
tatic gland. 

In the mildest form of chronic enlargement, the old man notices that he 
micturates oftener during the day than he used to, and that he has to rise 
a little earlier in the morning on account of a pressing desire to urinate. 
There is a sense of uneasiness, or actual pain of a stinging kind, extending 
along the penis, felt more especially at the glans. 

He has to wait a little time before the flow begins, and more or less 
straining is always necessary to start it ; then it comes slowly and cannot 
be projected in a jet ; indeed, it usually falls nearly perpendicularly from the 
urethra. After he thinks the act complete, several drops pass ; and in care- 
less old men, especially in summer, this is more inconvenient to others than 
to themselves. The stream is always small. 

After a time he is compelled to evacuate the bladder every hour or 
two, or there may be a continual dribbling, especially marked when the pa- 
tient is in a recumbent posture. 

There is no sense of satisfaction after micturition ; and just here it 
may be mentioned that, when excessive prostatic enlargement exists, there 
is a sense of incomplete evacuation of the rectum, and tenesmus is occa- 
sionally present at stool. For the same reason, hemorrhoids and prolapsus 
ani are by no means infrequent coexisting conditions. 

Any slight indiscretion in eating and drinking may bring on an attack 



200 CLINICAL LECTURES OX 

of retention. All -violent or jolting exercise, such as horseback-riding, in- 
creases the desire to micturate, and may cause slight pain along the course 
of the urethra, together -with flying pains in the hips, limbs, and about the 
pubis. 

The irritation from an enlarged prostate often excites such lascivious 
desires in old men that they become notoriously indecent. Such cases are 
common everywhere ; in every village there are one or two old men who 
are terrors to the maidens. 

In the severer form, the bladder is exceedingly irritable ; a sense of 
weight and fulness is experienced in the perina?um ; retention soon fol- 
lows, the other symptoms being those of the milder variety. 

The efforts made to expel the urine are often so severe that various por- 
tions of the mucous membrane, weaker than the rest, are pressed out, and 
sacculation of the bladder is the result. 

The urine decomposing in these sacs is one of the most favorable con- 
ditions for the formation of stone. 

When the outflow has been obstructed for some time, structural cbai 
occur in the muscular and mucous coats of the bladder ; there is usually a 
mild or severe chronic catarrh of the ureters and calices and pelvis of the 
kidney. 

Sometimes the bladder hypertrop hies and contracts, instead of becom- 
ing distended ; then irritability of the bladder becomes u marked and con- 
stant symptom. 

As the disease progresses, and when the mucous nienibrane is inflamed 
and ulcerated, the urine scanty and containing blood and jnis. the coun- 
tenance becomes sallow and indicative of organic disease. 

Finally, worn out by sleepless nights and continual pain, the aged suf- 
ferer sinks from exhaustion, retaining his faculties till the last ; or he dies 
more rapidly in a coma which was preceded by typhoid symptoms — a dry. 
brown tongue, general prostration, rapid, feeble, and irregular pulse, and 
low, muttering delirium. The urine may be alkaline or acid. 

The first changes in it are a fetid smell, and the presence in the m 
tion of viscid, string}' mucus. As the disease progresses, more and more 
of residual urine is left in the bladder, and we find it dark and mingled 
with gummy mucus. "SVhen vesical catarrh is present, the urine may have 
an almost milky appearance, from admixture of pus, and a horribly 

fetid and ammoniacal odor, blackening the silver catheter. It is rare to 
find the urine of an old man with enlarged prostate that does not contain 
pus-globules, blood-corpuscles, amorphous urates and phosphates, mingled 
with crystals of the triple phosphates and stringy mucus. 

A physical examination per rectum discloses a rounded or nodul 
lobular, dense tumor, in the region of the prostate gland. Pressure upon 
this tumor will usually excite a desire to urinate. 

Percussion may reveal an enlarged bladder. 

The catheter cannot be easily introduced into the bladder, on account 
of the obstruction it meets from the enlarged gland. In the attempt to 
explore the urethra a gum-elastic catheter should be used ; and if. in en- 
deavoring to make a diagnosis by catheterization, there is much difficulty 
and any doubt, Squire's vertebrated catheter, or the soft, bulbous-pointed 
prostatic catheter, is probably preferable to any other instrument 
can turn very abrupt curves. Besides, there are multitudes of instruments 
whicli it is unnecessary to enumerate for diagnosticating the amour.: 
situation of the urethral twisting and narrowing which come from hyper- 
trophy of the prostate. 



THE DISEASES OF OLD AGE. L>01 

Differential diagnosis. — Senile prostatic enlargement may be mistaken 
for atony of the bladder, stricture of the urethra, and stone in the blad- 
der. 

Atony is readily diagnosed from hypertrophy of the prostate by the 
manner in which the urine flows from a catheter. In enlargement of 
the prostate the flow is quite forcible, and can often be made more so by 
the patient's will ; whereas in atony of the bladder the urine merely flows 
out from the instrument, and no augmentation can be voluntarily made in 
its force by the patient. 

Stricture is not a disease of advanced life. In stricture there are no 
rectal evidences of a tumor on physical exploration, while these are present 
in hypertrophy of the prostate. In stricture there is usually a history of 
venereal disease, which may be absent in hypertrophy. A sense of incom- 
plete evacuation of the bladder is present in cases of prostatic enlarge- 
ment, and absent when organic stricture alone is present. 

The urine in stricture is normal, while in enlargement of the prostate it 
has the abnormal ingredients which I have just described. 

Again, the catheter meets an obstruction about six inches from the 
meatus in stricture ; and in enlargement of the prostate the distance of the 
obstruction is at least seven inches from the meatus. 

Stone is very difficult of recognition, as contradistinguished from a 
hypertrophied prostate. 

When blood is passed after exercise, it indicates the presence of a 
stone, and in the latter condition the difficulty in micturition has been 
as long and as steadily coming on as in enlarged prostate. 

The tumor in stone, if felt per rectum, is movable ; while it is immov- 
able in prostatic hypertrophy. The sound is the only means which we have 
of making a positive diagnosis. 

Prognosis. — We cannot cure enlargement of the prostate in old age, nor 
can we check its progress when once it is developed ; it is unquestionably a 
part of senile decay. Its duration, then, is indefinite. The outlook for 
comfort is best in those cases where there has never been complete reten- 
tion of urine. 

The effects of an enlarged prostate in the aged vary greatly, and neces- 
sarily modify the prognosis. A moderate enlargement of the " third " lobe, 
or of one or both of the lateral lobes is sometimes attended by retention of 
the urine and great difficulty in passing the catheter ; while cases where 
the autopsy has revealed a prostate as large as a base-ball had caused dur- 
ing life no difficulty with the urine and no obstruction to the passage of a 
catheter. 

This condition may become very grave from the complicating conditions 
which are rarely altogether absent during its course ; these are cystitis, 
pericystitis, vesical ulceration, overflow, inflammation of the ureters, pyeli- 
tis, nephritis, perinephritis, enlargement of the testicle, hemorrhoids, pro- 
lapsus ani, and ammonsemia. 

Treatment— We have no means of arresting the slowly advancing 
chronic enlargement of the prostate gland in advancing life. 

If anything will check its progress, it is a diet and mode of life which 
are the opposite to those which are known to favor rapid and extensive 

hypertrophy. ...,,, •* 

Alcohol, if used, must be used moderately, or it is better not to use it 
at all. The slightest call of nature to evacuate the bladder must be imme- 
diately obeyed. Horseback-riding is to be avoided. Flannels must be 
worn next the skin, the extremities especially being kept warm. 



262 CLINICAL LECTURES ON 

Ultimately the regular daily introduction of the catheter will become a 
necessity. 

As a rule, old men are yery much opposed to the introduction of an 
instrument into their bladders, and it may require much persuasion and 
a clear description of the exact state of affairs before they will permit it. 

Again, it is to be remembered that catheterism is sometimes dangerous 
in old men ; the following statements will tell } r ou at once not only to post- 
pone their use as long as possible, but it will also indicate to you the im- 
portance of gentleness and care in the manipulation : 

An old man, eighty, has been troubled with some difficulty in passing 
water. A bougie is passed carefully till it reaches the prostate, when it 
stops. It is then withdrawn, for no force is used to push it farther, and a 
little blood follows its removal After that day not a drop of urine passes 
except through the catheter. 

Another case resembles this precisely, except that, following the few 
drops of blood, there is complete retention, which results in death in a few 
days. 

The shock from a cold sound [wring over the prostate, even when 
slightly hypertrophied, may give rise to urgent symptoms, and has v 
death. 

Still a catheter must be introduced, and when introduced should be 
of the temperature of the body, the patient always standing during the 
operation. 

The bladder is to be emptied at least twice a day ; and if thei • 
tis, glycerine or biborate of soda may be added to the water used to wash 
out the viscus. 

Alkalies, administered witli flaxseed tea, are very good internal n 
dies when the urine is strongly acid. 

During warm weather, old men may not require the catheter ; In. 
soon as cold weather approaches, it will be necessary 
ngain. 

Retention and catarrh of the bladder demand prompt and appro}'! 
treatment, for in old age they rapidly bring <>n a condition which may end 
iu death. 

Ambon jeha. 

In connection with enlarged prostate and atony of the bladder, e 
the consideration of a disease which, though rare during adult life, is fri - 
quently met with in those advanced in life. 

Ammomemia is that change in the blood due to the presence of 
bonate of ammonia, which arises from metamorphosis of urea, the result of 
retention of the urine in the urinary organs. 

Thus it is evident why arnmonaniia is frequent in old age. for in that 
period of life atony of the bladder and enlarged prostate are frequent con- 
ditions. 

Morbid anatomy. — The urinary tract will present the appearance of 
Inore or less acute catarrh, as well as conditions favoring or causing urinary 
accumulations. 

There is always chronic catarrh in the intestines, and it has been ob- 
served that they were rilled with a greenish yellow mucus and an alkaline 
rluid, having an ammoniacal odor. 

Ulcers have also been found in the large \w: niilar to 

dvsenterv. 



THE DISEASES OF OLD AGE. 263 

It may be mentioned here that in the cases where ammonsemia occurs 
with uraemia, which is quite rare in the aged, it is possible for the urea 
excreted into the intestines to change into carbonate of ammonia, and thus 
bring about the pathological condition I have just described as sometimes 
existing. 

Rosenstein denies any connection between ammonseniia and poisoning 
by carbonate of ammonia, but the weight of opinion is against his state- 
ment. 

Etiology.— All that is required to produce ammonsemia is the retention 
of urine in the body sufficiently long to allow of the metamorphosis of its 
urea. 

Decomposition occurs very quickly, and of course, more rapidly in, than 
out of the organism, on account of the bodily warmth. 

Ammonsemia occurs with enlarged prostate, atony, and paralysis of the 
bladder. These are the chief causes in old age, although it may arise at 
that period from stricture of the urethra, sacculated kidney, pyonephrosis, 
and hydronephrosis. 

Symptoms. — Ammonsemia may be divided into two forms, according as 
the inducing cause is of sudden but permanent occurrence, or comes on 
gradually and steadily. 

In the first, the so-called "acute" form, there are nausea and vomit- 
ing, intermittent chills, acceleration of the pulse-rate, followed by a rise 
in temperature. Diarrhoea is also a frequent accompaniment of acute 
ammonaemia. 

The complexion rapidly becomes dingy and bronzed ; and there is great 
muscular weakness, with a tendency to lethargy and stupor. 

Rarely, however, are there any convulsions or oedema of the feet. 

The tongue is brown, dry, and shining — the " beefy tongue ; " the mu- 
cous membranes are remarkably dry, that of the throat especially ; and the 
perspiration and breath have a well-marked ammoniacal odor. 

In the "chronic" form, that which comes on in old men with enlarged 
prostates or atonied bladders, the complexion gradually passes from a sal- 
low to a dingy brown hue, and there is slow, but progressive ema- 
ciation. 

The aged patient is restless, has a slight headache, and insomnia be- 
comes a very distressing symptom. Now and then chills occur, but with 
no regularity, and vomiting is an important symptom. Meanwhile, as the 
complexion darkens and emaciation progresses, the mucous membranes 
begin to assume a dry, glazed, shining look, the skin becomes drier and 
drier, and the breath and perspiration take on a distinctly ammoniacal 
smell, but the amount of perspiration is greatly diminished. 

The temperature in these prolonged cases is constantly above the nor- 
mal ; and as the condition gets worse, the pulse is each day more and 
more accelerated. 

With these symptoms there will be no oedema of the feet, or, in the 
majority of cases, convulsions ; but the symptoms will rather counterfeit, 
to a very striking degree, those of chronic gastric catarrh. Persistent 
vomiting is often a prominent symptom. The bowels are usually consti- 
pated, although at times slight attacks of diarrhoea alternate with the con- 
stipation. 

Finally, after emaciation has become extreme, and a cachexia has been 
fully developed, the restlessness and insomnia give way to lethargy, stupor, 
and the patient passes into a typhoid condition. 

In old men with enlarged prostates this is quite a common termination. 



264 CLINICAL LECTURES ON 

the patient passing from stupor into the comatose state, with low, muttering 
delirium, rapid, feeble, and irregular pulse, and finally dying in a condition 
of deep coma. 

The urine is ammoniacal, and hence strongly alkaline wJien passed, fre- 
quently containing pus and depositing amorphous phosphate of lime with 
crystals of ammonio-magnesia phosphate. Its odor is as offensive as it is 
pungent. 

Differential diagnosis. — Senile ammomemia may be confounded with 
" typhoid gastritis," pyremia, and septicaemia. 

In typhoid gastritis the urinary symptoms are negative, in ammonaemia 
they are diagnostic. 

In gastric catarrh there is no particular odor to the breath or perspira- 
tion, while this is markedly ammoniacal in cases of ammoniacal poisoning. 

Nausea and vomiting may be prominent symptoms in chronic ammon- 
temia (the only form which would lead to confusion), while they are very 
slight or absent in gastric catarrh. 

In the amnionsemiaof the aged, the catheter or a rectal examination will 
show the existence usually of atony of the bladder, or hypertrophy of the 
prostate, while you will find no genito-urinary causes in typhoid gastritis. 

Pyaemia and aepticcemia may be mistaken for ammonamia, on account of 
the color of the skin and lethargic expression of the face. 

JnpyCBmia there is the history of a severe initiatory chill, profuse recur- 
ring sweats, high temperature — 102 to 104° — sweet, sicky breath, and an 
appearance of infarctions, thrombi, or multiple abscesses in some organ. 
None of these symptoms occur in ammonamiia; on the contrary, the odor 
of the breath, the condition of the urine, and the evidence of some me- 
chanical obstruction, would all be present, and with the other points would 
suffice to establish the diagn 

In septicemia the temperature is much higher (105 — 1<»7 ) from the 
onset; there are no recurring chills, no ammoniacal odor to the breath or 
body, and no urinary evidences such us are found with ammoniemia. 

And finally, in both pyaemia and septicemia the skin is in a strikingly 
opposite state to that of ainmonamia. being for the most of the time bathed 
in a copious perspiration, while in the la: Iry. harsh, and 

has an ammoniacal odor. 

Prognosis. — The prognosis in ammonamia ia determined to a great ex- 
tent by the conditions which cause it 

AYhen their removal is possible— as in retention of mine from enbu 
prostate — the prognosis is favorable. 

When it is due to pyelitis or sacculated kidneys, it is very bad : in all 
cases there is a gradual and steady impoverishment of the general health ; 
old people suffering from any blood-poison are liable to sink rapidly into a 
typhoid state if the conditions which give rise to the poisoning cannot be 
speedily removed. 

Treatment. — Its treatment consists in removing r 
sible in a large proportion of cases, since atony of the bladder and hyp* 
phied prostate are by far the most frequent conditions. 

Very often, when the aged patient seems fatally sinking, and when no 
suspicions have been attached to the bladder, you may draw off a barge 
quantity of stinking urine, and then, with subsequent washing of the 
viscus, a rapid improvement takes place, and the gastric symptoms subside. 

The diet of this class of patients should always be supporting and stim- 
ulating. 

Atony of the bladder and hypertrophy of the prostate must be fan 



THE DISEASES OF OLD AGE. 2G5 

according to the rules already given, and the catheter will here be most 
useful, and should be passed at least twice every day. 

To the tepid water used to wash out the bladder, you may add, at dis : 
cretion, carbolic acid, biborate of soda, or glycerine. 

The w T ashings should be continued until the withdrawn fluid is per- 
fectly clear and inoffensive in odor. 

The treatment of this condition, beyond the removal of the cause, re- 
solves itself into supporting and nourishing the patient, and relieving those 
catarrhal inflammations which have been excited by the ammoniacul poi- 
soning. 



Fig.l 



■■ 






Fig. 2. 



Plate I 



Fig. 3. Fig. 4 Fig 











\ 



DESCRIPTION OF PLATES. 



PLATE I 

Fig. 1. — Right hand of a man sixty-nine years old, attacked with gout since 
his thirty-third year. A large tophus is seen at the base of the index-finger, on 
a level with the metacarpo-phalangeal articulation. A second tophus, smaller 
than the preceding, is situated at the base of the middle finger. There are nu- 
merous concretions of urate of soda upon the external ear of this man. 

Fig. 2. — Left hand of a gouty woman, eighty-four years old, who died in the 
Ralpetriere, in 1863. Both hands were symmetrically" affected, and to the same 
degree ; there was no appearance of tophaceous concretions in the vicinity of 
the joints. Here we find an exact reproduction of one of the types of deformi- 
ties of the upper extremities most frequently seen in progressive chronic articular 
rheumatism. The articular cartilages of the metacarpo-phalangeal articulation 
were encrusted with urate of soda. Upon the dorsal aspect of the metacarpal 
heads there were, besides, tophaceous deposits which, situated immediately 
beneath the skin, and pressed against the heads of the bones, were flattened, 
forming no appreciable projection upon the back of the hand ; this occurred in 
such a way that, before dissection, their existence could not be recognized. 

Pegs. 3, 4, 5, and 6. — These refer to the anatomy of Heberden's nodes. In 
Fig. 3 the second phalangeal articulation is seen deformed, but still covered 
by the soft parts. The pisiform projections described by Heberden are well 
marked. 

Fig. 4 shows the ends of the bones laid bare by dissection; the articular 
surfaces are broadened in all directions and thickened, on account of the forma- 
tion of osteophytes. 

Fig. 5. — The same preparation viewed laterally. 

F IG . 6. — Normal condition, with which Fig. 4 is to be compared. 



PLATE E. 

Figs. 1 and 2. — Deformity of the hands in general chronic articular rheuma- 
tism. The characteristics of the first type are well shown in Fig. 2. Fig. 1 
gives a good idea of the deformities occurring in the second type. 

Fig. 3. — Changes in the mitral valve in a case of primitive general chronic 
articular rheumatism. 



Fill- 



Plate II 







Fig. 2 






Fig. 3. 



Bf @ 





F*2. Att 



Plate IE. 






Fig. 3. 



Fig. 4. 





in 



Fig- 5- 





PLATE m. 

Fig. I.— Gouty nephritis.— -Part of a section of the kidney (10 diameters) ; 
the white, chalky-looking lines (a) are deposits of nrate of soda occupying the 
medullary (tubular) substance. These are represented in Fig. 3, magnified 150 
diameters. 

Fig. 2. — A convoluted uriniferous tubule of the cortical substance, whose 
epithelial cells (b), large and clouded, are also filled with fatty granulations. 
(300 diameters.) 

Fig. 3. — Crystals of urate of soda (d), forming the deposit in Fig. 1 (a), visi- 
ble to the naked eye. (Section of the tubular portion, 150 diameters.) 

Fig. 4. — This figure has reference to the period of dissolution of these de- 
posits under the influence of acetic acid. The free crystals are dissolved, and 
nothing remains but an amorphous deposit (e), which slowly goes on dissolving. 
It is then very clearly seen that a portion of this deposit is situated in the inte- 
rior of the uriniferous tubules (g). (Section of kidney, 200 diameters.) 

Fig. 5. — Synovial fringes from the knee-joint covered with their epithelium, 
and exhibiting at (m) a deposit of urate of soda, generally amorphous. (N. B. 
— These different preparations are from a gouty woman eighty-four years old, 
who died in the Salpetriere, in 1863, and whose right hand is pictured in Fig. 2 
of Plate I.) 

-pio. 6. — L e ft ear of I. M , an old coachman, born in Poland in 1807, and 

in whom the first attack of gout occurred at the age of twenty-five. [Hopital 
Rothschild; service of Dr. Worms.) 

h, h, h. — Large concretions of urate of soda. These tophi, so the patient 
says, commenced to appear three years after the first attack of articular gout. 



INDEX. 



Abscess, atheromatous, 22, 23 

pulmonary, symptoms of, 203 
Acid, lithic, discovery of, 95 
Acid, uric, amount of, in gout, 42 

discovery of, 41, 1)5 

proportion of, in gout, 41 
Adams, 101, 104, 143, 144 
Affections, chronic, 10 
Alcoholic intoxication, and apoplexy, dif- 
ferential diagnosis of, 234 

and cerebral hemorrhage, differential 
diagnosis of, 234 
Alcoholismus, chronic, in animals, 14 
Aldrovini, 53 
Algidity, central, 184 

drugs which produce, 180 

experiments in the production of, 187 

in cardiac diseases, 189 

in endocarditis, 189 

in pericarditis, 189 

in peritonitis, 190 

in pleurisy, 190 

in pneumothorax, 190 

semeiotic value of, 37 
Ammonaemia and pysemia, differential 
diagnosis of, 264 

and septicaemia, differential diagnosis 
of, 2(54 

typhoid gastritis, differential diagno- 
sis of, 264 
Ammonaemia, 262 

differential diagnosis of, 264 < 

etiology of, 263 

morbid anatomy of, 262, 263 

prognosis of, 264 

symptoms of, 263, 264 

treatment of, 264, 265 
Anaemia, algidity in, 185 

senile. 224 
Anatomy, of ancients, 6 

modern, 8, 9, 10 

pathological limit of, 9 

senile, 20 

"the dead," 10 

the new, 10 
Ancients and modems, comparison be- 
tween, 8-10 
Andral. 121 



Angina, in the gouty, 74 

pectoris and asthma, differential diag- 
nosis of, 2L9 
Ankylosis, 47 
Anoxaemia, 172 
x\nthrax, uric acid, 73 
Antagonisms, doctrine of, 75 
Aorta, atheroma of, 51 
Aphasia a symptom of gout, 67 
Apoplexie foudroyante, 233 
Apoplexy, 231 

and alcoholic intoxication, differential 
diagnosis of, 234 

and cerebral congestion, differential 
diagnosis of, 234 

and embolism, differential diagnosis 
of, 234 

and uraemia, differential diagnosis of, 
234 

differential diagnosis of, 234 

etiology of, 232 

morbid anatomy of, 231, 232 

prognosis of, 234, 235 

rheumatic, 67 

symptoms of, 232-234 

treatment of, 235 
Appendix to Lecture IX., 92 
Arcus senilis, 66, 228 
Arfwedson, 160 
Arteritis deformans senile, 224 
Arthritides, 71 

Arthritis, chronic rheumatismal, character- 
istics of, 105 

histological study of, 106 
Arthritis deformans, 143 

characteristics of, 144 
Arthritis, from prolonged rest, 112 

fungous, 112 

pauperum, 19 

rheumatoid, 101 

scrofulous, 112 
Arthrocace senile, 145 
Arthropathies, gouty, 113 

secondary, 113 

symptoms of, in acute articular rheu- 
matism, 117 

tertiary, 113 
Articulations in gout, 45 



INDEX. 



Ascites and paralysis of the bladder, dif- 
ferential diagnosis of, 250 
Asthma and angina pectoris, differential 
diagnosis of, 219 

and bronchitis, differential diagnosis 

of, 219 
and emphysema, differential diagnosis 

of, 219 
and laryngeal spasm, differential diag- 
nosis of, 219 
and pericarditis, differential diagnosis 

of, 219 
and pulmonary oedema, differential 
diagnosis of, 219 
Asthma, 21(5 

4 'cardiac," 217 
differential diagnosis of, 9 1 B 
etiology of, 216 
gouty, 08 
• nature of, 216 
'peptic," 216 
physical signs of, 218. 21!) 
prognosis of, 22(1 
symptoms of, 2 Hi 
treatment of, 220, I 
Atheroma, 221 
Atrophy, cerebral, 848 

differentia) diagnosis of, 211 
etiology of, MO 
morbid anatomy of, 210 
prognosis of, 247 
symptoms of. 210 
treatment of. 211 

Auduran's wine. 157 

Aurelianus. (Julius. 80 

Auscultation, modifications of, in old age, 

204 
Autenrieth, 18 
Auto- toxaemia, 172 



Babington, 113 

Bacon, L2 
Baglivi, 18 
BaiUarger, 87 
Baillou. 89 
Hal four 
Ball, 78 
Bamberger, 129 

Banish," 164 

liarensprung, 30 
Bartek 
Basham, 69 

liastien, 21 
Beyle, 8 

Baynard, 122 

iiazin, 71, 133 

Beau, 20. 81. 140, 164 

lVequerel, 121 

Beers, English, 02 

Begbie, H>4 

Bence-.Tones. 51, 75, 98 

Benek< 

Bennett, 8S 

Bergmenn, 187 

Bernard, Claude, 3, 13, 70, 100. 174, 190 



I Bibra, 22 
' Bichat, 3 

| Billroth, 182, 186, 187 
Biology in medicine, 4 
Bird, 43 
Bocker, 141, 158 

experiments of, 98, 141. 168 
i Boerhaave, 4, 29, 81, 173, 174 
Bonnet, 112 
Borden, 4 

Bouillard, 30, 110, 121. 124, 129 
Boyer. 118 
Bladder, atony of, 254 

and hypertrophy of the prostat. . dif- 
ferential diagnosis of, 201 
Bladder, in gout. 

irritable, in gout, 09 
Bladder, paralysis of, 2">4 

and ascites, differential diagm 

856 
and retention of urine, differential 

diagnosis of, S 
differential diagnosi- 
etiology. 254, . 
prog 
symi 

treatment 
Bladder, stone in, and hypertrophy of the 

prostate, differential diagnosis of, . 
Blagden and Dobson. experiments o: 
Blood, changes in, in old age, 224 

of, in gout, 43 
Bramson. 51 
Brand, 175 

lea, 188 
Briuton, 86 
Broadhurst 
104 
Bro<: 

Bronchiecta- d signs of. 

Bronchitis, capillary, and pneumonia, dif- 
ferential diagru 
Bronchitis, chronic. J 

differential diagnosis of. 
etiol< \ 

morbid anatomy of. 209. 210 
physical signs of, 21 . 
prognosis of, 21:?. 214 
symptoms of. 210. 212 
treatment 
Bronchitis, chronic, and asthma, difT- 
tial diagm « 

and phthisis, differential diagno>> 
813 
Bronchorrhaa. 211. 212 
Broussais. 3. 11 
Brown-S. quard. ■. 
Bucquov. M 
Budd, 60, 04. 66, 86, 
Burrow 



Caldwell. 28 
Calliburees. 174 
Calorification, inhibit 
Cancer, algid 



INDEX, 



273 



Cancer and gout, 80 

Canstatt, 120 

Cardiopathies, rheumatic, septicaemia in, 

128 
Carditis, polypoid, 124 
Carinichael, 72, 73 
Cartilage, articular, in gout, 45 
Cartilage, changes of, in chronic rheuma- 
tism, 10b* 
Cartilage, diarthrodial, in gout, 45 
Cartilages in abarticular gout, 70 

incrustation of, 47 
Cart wright. 159 
Castro, Koderic a, 61 

Catarrh, chronic bronchial, differential 
diagnosis of, 213 

etiology of, 210 

morbid anatomy of, 209, 210 

physical signs of, 212, 213 

prognosis of, 213, 214 

symptoms of, 210, 212 

treatment of, 214, 215 
Catarrh, chronic bronchial, and phthisis, 

differential diagnosis of, 213 
Catarrh, ''dry," 211 

Catarrh, gastric, anorexia as a symptom of, 
243 

differential diagnosis of, 244 

etiology of, 242, 243 

flatulence as a symptom of. 243 

heart-burn as a symptom of, 243 

morbid anatomy of, 241, 242 

prognosis of, 245 

pyrosis as a symptom of, 243 

symptoms of, 243, 244 

treatment of, 245, 247 
Catarrh, gastric, and atonic dyspepsia, dif- 
ferential diagnosis of, 244 
Catarrh of the bronchi, senile, 201) 

pituitous, 211 

senile gastric, 211 
Cazalis, 80 

Cephalalgias, gouty, 07 
Chalk-stones, 46 
Changes, local, in gout, 45 
Chegoin, H. de, 6Q 
Chelius, 158 

Cheyne-Stokes dyspnoea, 228 
Chill in old age, 31 
Cholera, 37 

Asiatic, algidity in, 181 
Chomel, 104, 121, 149, 153 
Civiale, 70 
Clin, 60 
Cloetta, 97 
Cnidian school, 6 
Colchicum, in the treatment of gout, 157 

physiological effects of, 158 
Cold, death from, 175 
Colly, 84 
Collapse, 191, 192 

in malaria-poisoning, 193 

in small pox, 193 

in the plague, 193 

in typhus fever, 193 

in yellow fever, 193 
18 



I Colles, 101, 104, 145 
Colombel, 144 

Congestion, rheumatic pulmonary, 131 
Conjunctivitis, rheumatic, 133 
Constipation, senile, 250 

differential diagnosis of, 252 

etiology of, 250 

prognosis of, 252, 253 

symptoms of, 250 

treatment of, 253, 254 
Constitutions, medical, doctrine of. 6 
Contractions, muscular, cause of deformity 

in nodular rheumatism. 140 
Convulsions, a symptom of gout, 67 

a symptom of rheumatism, 67 
Cooper, Astley, 258 
Copland, 117 
Cornil, 105, 133 
Corpuscles, Gluge's, 236 
Corradi, 84, 85 
Corvisart, 3 
Cos, school of, 6 
Crises, theory of, 7 
Cruveilhier, 9, 19, 41, 49 
Cullen, 64 



Darembf/rg, 5 

Daubenton, 23 

Davy, 53 

Day, 20 

De Castelnau, 51 

Dechamps, 69 

De Haen, 30, 167 

Delle-Chiaje, K4, 149 

De Martini, 43 

De Mussy, Gueneau, 164 

Derangemeuts, functional, 11 

De Rennes. 159 

Deville, 104 

Diabetes. 27 

algidity in, 185 
Diabetes and gout, 75 
Diabetes, metastatic, 75 

symptomatic, 75 
Diarrhoea, senile, 247 

differential diagnosis of, 248 

etiology of, 247 

prognosis of, 248 

symptoms of, 247, 248 

treatment of, 248, 250 
Diatheses, 8 

gouty, influence of, 44 
Dietrich, 50 

Digestion, physiology of, in old age, 241 
Dilatation, cardiac, and fatty heart, differ- 
ential diagnosis of. 229 
Disease, ancient views of, 3 
Diseases, acute and chronic, distinction 
between, 8 

constitutional conception of, 8 
Diseases, febrile, of the continued type, 177 

of the intermittent type, 178 

of the remittent type, 178 
Diseases, latent, 27, 28 

in old age, 27 



274 



INDEX. 



Diseases of old age, general characteristics 

of, 18 
Diseases, peculiarity of, in old age, 24 

special, of old age, 24 

with subnormal temperature, 37 
Dundas, 85 
Durand-Fardel, 19 
Dyspepsia, 244 

atonic, and catarrh of the stomach, 
differential diagnosis of, 244 

follicular, 241 

gouty, 52 



Ear, diseases of, in abarticular gout, 71 
Eczema, 133 

in gout, 70 
Edwards, 51 

Embolism and apoplexy, differential diag- 
nosis of, 234 
Embolism and hemorrhage, cerebral, dif- 
ferential diagnosis of, 234 
Embolism, experimental, 13 
Emphysema and asthma, differential diag- 
nosis of, 219 
Encephalomalachia, 336 
Encephalopathy, rheumatic, 132 
Endocarditis, 124 

arterial emboli in, l'J7 

capillary emboli in, 127 

capillary embolism of kidnev in. 128 

liver in, 128 

pathology of. 125 

splenic embolism in. 128 
Endocardium, histology of. 133 
ESngel, 75 

Environment, theory of, 
Epilepsv, essential rise in temperature in, 

171) 
Erasmus, 78 
Erb, L83 
Erysipelas, 81 

in the gouty, 73. 74 
Erythema nodosum, 153 



Faber, C6 

Falconer, 90 

Fatalism, geographical, G 

Fever, characteristics of, in rid ago. 89 

Fever, definition of, 29 

in old age. 86 

intermittent. 31 

phenomena of. 89 

rheumatic. 117 

symptomatic intermittent 

theory of, 178 

thermometry in. 90 

traumatic experiment;!!. E> 
Fevers, in old age, 24 

malarial, 178 
Fibrous tissue in abartieular gcut, 70 
Fischer, 180 
Fisher, 18, 75 
Floyer, 18 
Forbes, Murray, 41, 95 



Fourcault and Edenhuisen, experiments 

of, 174 
Frolich, 186 
Fuller, 84, 101, 110, 119, 120, 122, 132, 

133, 150, 155, 164 
Funke, 11 



Galen, 29, 61 

Gallois. 78 

Gangrene, dry, in the gouty, 73 

pulmonary, symptoms of, 203 

senile, of extremities. 83 
Garrod, 41, 42, 43, 49, 51, 52. 57. 59, 60, 

63, 65, 66, 68, 69, to. 71, 73, 

'.mi. 100, 101, 117, 132, 133, 150, 153, 
154, 158. 160, 164 
Gastritis, catarrhal. 241 
Gastritis, typhoid and ammonaemia, dif- 
ferential diagnosis of, 264 
Gavarret. 30, 121 
Geist, 2ii, 23 

Generative functions in old age, 23 
Geuth. 05 
Gerhardt, 175 

Germany, physical diagnosis in, 15 
Gillette, 28 
Glands, salivary changes in, in old age, 

241 
Glycosuria, experimental, 13 
Gorget, 1 1 
Goupil. 159 
Gout, abarticular, 70 

action of certain drugs in. 74 
Gout, u 

deviations from regular type of 

diseases of the intervals. 41 
• xysm. 41 

functional derangements in, 41 

general, 40 

local symptoms of, 5 

parti;. 

primitive general. 57 

prodromata of, 55* 

regular type of. 57 

symptoms of, 56 
Gout, age in the causes of, V T 

alcoholic beverages as causes of, 91 

alkalies in the tieatmeut of, 160 

alternating. 40 

ammoniated tincture of guaiacum in 
the treatment of. 

analytical study of the causes i 

anomalous treatment of, 163 

antiquity i 

at on 

blisters in the treatment of. I 

cerebral symptoms of, and d< 
tremens. 

characteristics of new attacks ( 
Gout, chronic. 40, 58-60 

attacks in. 41 

characteristics of. 59 

permanent lesions in. 41 
Gcut. climate in the ce 



INDEX. 



Gout, colchicum in the treatment of, 157 

comparative pathology of, 52 

concomitant diseases of, 72 

constitution in the causes of, 87 

" critical," 74 

Cullen's theory of, 96 
. debilitating causes of, 91 

dietetic regimen in the treatment of, 
163 

diminution of, in modern times, 84 

etiology of, 81 

excess in eating as a cause of, 87 

exciting causes of, 91 

experimental pathology of, 52 

fermented liquor as a cause of, 88 
Gout, gastric, 63, 64 

varieties of, 64 
Gout, general characteristics of, 40 

general considerations in the treat- 
ment of, 156 

historical pathology of, 82 

hyoscyamus in the treatment of, 157 

individual causes of, 86 

indigestion as a cause of, 91 

intellectual labor as a cause of, 91 

intercurx-ent diseases of, 73, 74 

iodide of potassium in the treatment 
of, 159 

lead-poisoning as a cause of. 90 

leeches in the treatment of, 159 

lithium in the treatment of, 160, 161 

liver in, 0d 

masked, 61, 62 

morbific material in, 39 

medical geography of, 85 

metastasis in, 63 

mineral waters in the treatment of, 
161 

misplaced. 62 

misplaced treatment of, 163 

moxa in the treatment of, 159 

narcjtics in the treatment of, 159 

nervous intiuence as cause of, 87 

nervous system in, 67, 68 

non-visceral, 70 

opium in the treatment of 1 59 
Gout, pathological blood conditions of, 
41 

physiology of, 81 
Goub, pathology of, 95 

permanence of the characteristics of, 
84 

potash salts in the treatment of, 160 

primitive asthenic, 19 

princip il forms of, 54 

purgatives in the treatment of, 159 

quinine in the treatment o:, 159 

rational theory of, 95 

respiratory apparatus in, 68 

retrocedent, 40, 50. 62 

return of attack of, 58 

rheumatic, 101 

Scudamore's theory of, 96 

sex in the causes of, 87 

soda-salts iu the treatment of, 160 

temperament in the causes of, 87 



Gout, tonics and stomachics in the treat- 
ment of, 163 

topical remedies in the treatment of, 
159 

traumatic causes of, 91 

treatment of, 156 

treatment of a paroxysm of, 157 

treatment of the constitutional con- 
dition of, 160 

treatment of tophi in, 161 

venereal excess as a cause of, 88 

visceral, 50 

definition of, 62 

organic lesions of, 63 
Gout, want of exercise as a cause of, 87 

wet cold as a cause of, 91 
Gout and rheumatism, 80 
Gouty patients, uric acid in blood of, 40 
Gravel and gout, 78 
Gravel, biliary, 26 
Gravel, uric acid, 75 

and gout, 75 
Gr ives, 16, 68 
Great-toe, invasion of, in gout, 47 

preferable attack of, in gout, 99 
Gregory, 158 
Griesinger, 67, 76, 132 
Grisolle. 110 
Gubler, 67 
Guiibert, 64, 75, 141 
Gurlt, 111 
G;",terbock, 184 
Guttman, 160 



Hahn, 75 
Halford, 150 
Haller, 12 
Hamernjk, 80 
Hammond, 158 
Hardy, 118 
IHaney. 3. 97 
lHasse, 111 
! Hattier, 108 
I Haygarth, 102, 104, 150 
Headache, rheumatismal, 67 
Heart, auscultation of, in old age, 225 

changes in, in old age, 223 

fatty degeneration of, in gout, 66. 67 

percussion of, in old age, 225 

senile softening of, 227 

state of. in gout, 6(5 

urate of sod i in valves of, 51 

varieties of, 226 
Heart, fatty, 226 

differential diagnosis of, 229 

etiology of. 227 

infiltration of, 227 

prognosis of. 229 

morbid anatomy of, 226, 227 

physical signs of, 229 

Quain's, 226 

treatment of, 229. 230 
Heart, fatty, and cardiac dilatation, dif- 
ferential diagnosis of, 229 
Heat, animal, drugs that increase, 186 



276 



IXDEX. 



Heherden, 155 

llecker, 84 

Heller, 98 

Hemorrhage, cerebral, 231 

and alcoholic intoxication, differential 
diagnosis of, 234 

and cerebral congestion, differential 
diagnosis of, 234 

and embolism, differential diagnosis 
of, 234 

and urasmia, differential diagnosis of, 
234 

etiology of, 232 

morbid anatomy of, 231, 232 

prognosis of, 234, 235 

symptoms of, 232-234 

treatment of, 335 
Heredity in gont, 86 
Herder, 
Herrmann, 128 
Herschell, 6 
Heynsius. 1 1 
Hippocrates, 8, 0, 7, 20 
Hirsoh, N5 
Hiato-chemistry. 1 1 
Histology, pathological, object of, 11 

the doctrine in, 10 
Holland, 41,70 

Honrmnnn and Dechambre, 19, 2? 
Humors, uric acid in, 43 
Hunter, 3 J, 75, 105 
Huss. 38 
11 vde- Salter, 08 



Litm-chemistry, 5 
I atro- mechanism. 5 
Identity, doctrine of, 88, 89 
Immunities, pathological, in old a^e, 24 
Infarctions, visceral, 83 
Juopexia, 12,' 
I. .filtration, cellular. 88 > 
Insanity, rheumatic. 132 
Intestines, changes in, in old age. 241 
Introduction. 1 
Iritia in abartumlax gout, 71 
rheumatic. 133 



Jacks. 1215 
.Tahn. 41 
Jenkinson, 164 

Joints in acute and subacute rheumatism, 
109 

attacked in gout, 48 

changes in diseases independent of 

rheumatism. 112 
deformity of. in nodular rheumatism, 

139, 140 
inflammation of. in gout. 40 
Joints, nodosities of, 102 

locomotor ataxy in, 133 
J.rgensen. 175 



Kidney." capillary embolism of, 128 



Kidney, diseases of, in gout, 69 

functional derangements of , in gout, 69 

gouty. 79 

granular, 52 

gravel of the, 51 
Kirkes. 127 

Kreisig, 124 • 

Kussmaul, 111, 188 



Laborde, 150 

Laennec. 3, 9 

Lancereaux, 113, 128 

Landre-Beauvais, 19, 101, 102. 104 

Lartigue's pills, 157 

Laryngeal spasm and asthma, differential 

diagnosis of, 219 
Laryngitis, chronic rheumatic, 132 
Laaegae, 104 
Latham, 129 
Laugier. 71 
Laville. liqueur de. 76 
Laville's liquid, 1~7 
Lawrence, 71 
L<ud in the goutv. 74 
Lel.eit. W, 110, 121 
Legnlloia, 10, 12 
Legroox, 121 
Lenpoldl 
Levden 
Liclu-n. 133 
Lichtenfels, 

Lieberxneiater, 173, 174. 175 
Lientery. senile. 24 7 

nts in abarticular goat, 70 
in gout. 4'! 
Lightning, death from stroke of. 12 

Littrc, :'.. 7 

Liver, enncer of. 27 

state of, in goal 
in, 54. 1(4 
Longet, ; !. 13 
Lorain. 153, 153. 154, 1^4 
Louis, 119, 

ardt, 185 
Lower, 13 
Lowy. 01 

Lunacy, rheumatism nl. f>7 
Lungs, capacity of. in old age, 194 

physiological changes in old age in the, 
195 

senile changes in the, 194 
Lnaohka, 
Lynch. (54, 07 
Lyon, Potton de, 04 



Maelaehlan, 858 

Haclagan, 858 
Macleod, 110, 117. 150 
Magondie, 10. 12, 190 
Malcolm son. 149 
Malgaigne, 106 

Malono. 98 

Mania, algidity in, 1S5 



INDEX. 



277 



Marcet, 68 

Marchal, 72, 73 

Marey, 23, 86 

Martel, 130 

Meyer, H., 105 

Mead, 157 

Medicine, empirical and sc'entific, 2, 8 

empirical, true character of, 4 

histology in, 10 

modern fundamental principles of, 3 

physiology in, 13 

result of science in, 14 

revolution of, in Germany, 15, 16 

scientific tendencies of, 15 

the microscope in, 10 
Membrane, synovial, changes in chronic 
rheumatism in, 106 

in gout, 46 
Mentegazza, 190 
Mercury in the gouty, 74 
Mesnet, 67, 132 
Mettenheimer, 20 
Michael, 30 
Mischerlich, 160 
Mitchell, 133 

Morbus coxae senilis, 103, 143 
Monneret, 30, 118, 119, 120, 157 
Monti, 179 
Moore. 59 
Morehouse, 133 
Morgagni, 3, 72, 78 
Murchison, 24, 59, 74 
Murexide test, 46 
Muller, 3, 15 
Murray, 78 

Muscles in abarticular gout, 70 
Musgrave, 90, 104, 153 



Nasse, 121 

Naturalism, 5 

Necraemia, 188 

Nephritis, albuminous, in gout, 69 

gouty, 51 

parenchymatous, 51, 52 
Nerves in abarticular gout, 70 
Nervous system in old age, 23 
Neumann, 75 
Nodi digitorum, 103 
Nodosities of Heberden, 143, 146 

pathology of, 146, 147 
Nutrition in old age, 24 



Obesity and gout, 77 
Object of the course, 1, 17 
QSdema, pulmonary, and asthma, differen- 
tial diagnosis of, 219 
Oesophagus, implication of, in gout, 63 
O'Ferral, 120 
O' Henry, 43 
Old age, atheroma of arteries in, 22 

atrophy in, 21 

brain in, 22 

cerebral arterioles in, 22 



Old age, external appearance in, 21 

fatty degeneration in, 21 

heart in, 21 

kidneys in, 21 

muscles in, 21 

pigmentary degeneration in, 21 

stature in, 21 

textural changes in, 20 

weight in, 21 

works on, 18, 19, 20 
Olliver, 110, 129 
Opium in the gouty, 75 
Ormerod, 129 

Osteopsathyrose, arthritic, 104 
Osteosarcoma, 145 
Owen, 84 



Paget, 22 

Panum, 174 

Paralysis, general, of the insane, 179 

Parry, 64, 90 

Pathology, anatomy and physiology in, 3, 5 

experimental, 13 

Hippocratic, 7 

relation of physiology to, 12 

senile history of, 18 
Patissier, 68, 86 
Percival, 145 
Percussion, modification of, in old age, 

203 
Pericarditis, 124 

acute, experimental, 13 

and asthma, differential diagnosis of, 
219 
Pericardium, white spots on, 224, 225 
Perry, 50 

Perturbations, critical, 35 
Petit, 43 

Phlebitis, visceral, 31 
Phlegmasia? in the gouty, 73 
Phlegmon in the gouty, 73 
Phthisis, algidity in, 185 
Phthisis and gout, 77 

' Phthisis and senile bronchitis, differential 
diagnosis of, 213 
Phthisis, gout, and scrofula, 79, 80 
Phthisis pulmonalis, relation of rheuma- 
tism to, 132 
Physiology a support to medicine, 5 

experimental, 3, 10 

modern purpose of, 12 

of ancients, 6 

pathology, 11 

senile, 20 
Pinel, 18 
Piorry, 120 
Plague, the, 28 
Plate I., description of, 267 
Plate II. , description of, 268 
Plate III., description of, 269 
Pleurisy and pneumonia, differential diag- 
nosis of, 207 
Pleurisy, experimental, 13 

gouty, 68 

in the gouty, 74 



278 



INDEX. 



Pleurodynia, G8 

gouty, 70 
Pneumonia, algid, 192 

bilious, 203 

defervescence in, 34, 35 

experimental, 13 

gouty, 08 

in the gouty, 74 
Pneumonia, lobar, 27, 30 

symptoms of, 32 

temperature in, 32, 33, 34, 
Pneumonia, lobular, 32, 33, 34 
Pneumonia and capillary bronchitis, dif- 
ferential diagnosis of, 200. 207 

and pleurisy, differential diagnosis of, 
207 

differential diagnosis of, 200, 207 

etiology of, 107 

expectoration in, 198 

face in, 201 

gastric symptoms in, 202 

headache in. 2u2 

modes of termination of, 190 

morbid anatomy of, 105, 107 

pain in, 900 

physical signs of. 198, 306, 206 

prognosis of. '207. 208 

respirations in. 200 

symptoms of, 198 

temperature in, l'JO 

treatment of, 208 

uriue in, 202 
Potton, L68 
Price-Jones. 74 
Process, thread, 42 
Pruner-Bey, 140 
Prurigo, arthritic. 188 
Prostate, chronic enlargement of, 257 
Prostate, hypertrophy of, 857 

differential diagnosis of, 2G0, 881 

etiology of. 

morbid anatomy of, 257, 

prognosis of. 201 

symptoms of. 250, 200 

treatment of, 861, S 
Prostate, hypertrophy of. and atony of 

the bladder, differential diagm 
861 

and stone in the bladder, differential 
diagnosis of, 861 

and urethral stricture, differential 
diagnosis of. 201 

prognosis of. 861 

symptoms of, 250, 260 
Prout, 66, 72, 78, 75. 70, 188 
Prus, 10 
Psoriasis in gout. 70 

nomnlar, 138 
Pulse, in old age. 88, 225, 000 

frequency of, in old age, 100 
Pyannia and animonaunia, differential 
diagnosis of, 204 



Quain, 00, 07 
Quo tele t. 81 



Ramollissement, cerebral, 20G 

Ranke, 97 

Ranvier, 105, 110, 112 

Rayer, 24, 41, 51. 70. 72, 75, 198 

Reaction, want of, in old age, 27, 28 

Rectum, torpor of the, 250 

Redfern, 105 

Reil, 11 

Remak, 133 

Reouin, 4, 121, 140, 153 

Respiration, character of, in old age, 

Respiration in old age 

Reynolds' elixir. 157 

Rheumatism, age in the etiology of, 150 

Rheumatism and gout 

comparison of etiology of, 154 
Rheumatism, acute, chorea in, 188 

duration of. 121 

muscular paint in. 

pathological blood condition in, 121 

seci 110 

urine in, 190 

vesical dipeaeee in. 
ral affections of 
Rheumatism, acute articular. 116 

arthropathies in. 1 17 

compared with gout. 120 
Rheumatism, articular, etiology of, 

blennorrhagic. 152 

chlorosis in. 158 

:i between acu* 
i, 196 

constitutional condition in, 118 
117 
imenorrhoae in, 153 

endocarditis in. 121 

ex . 

frequem 

gonorrheal. 152 

I 108, 134 

heredity in the etiology of. 149 

historical patholog 

influence of poveity in, 151 

its resemblanct 

medical g< -. 148, 140 

pathological < 

is in, 124 

sex in the i 

wet cold in the etiology of, 151 
Rheumatism, chronic, abarticular diet 
in, 131 

acute pneumonia in, 181 

alkalies in the treatment 

ammoniated tincture of guaiacum in 
the treatment of. 105 

anatomical eharae:< 

arsenic in the treatment of. 164 

asthma in. 131 

bloodletting in the treatment i : 

cerebral diseases in. 
. 138 

emphysema in, 131 

iodide of i>otassiuin in t!. 
of. 105 

local remedial in t" ent of, 

105 



INDEX. 



279 



Rheumatism, medullary affections in, 133 

mineral waters in the treatment of, 
165 

muscular pains in, 133 

opium in the treatment of, 164 

paralysis agitans in, 133 

paraplegia in, 133 

pericarditis in. 128, 130 

pleurisy in 131 

principal varieties of, 102 

quinine in treatment of, 164 

skin diseases in, 133 

tincture of iron in the treatment of, 
164 

tremor in, 133 

unity of, 104 

varieties cf, 134 

visceral affections in, 123 
Rheumatism, chronic articular, 38 

anatomical lesions of, 101 

modifications in forms of, 108 

treatment of, 164 
Rheumatism, chronic progressive articu- 
lar, 102 

symptomatology of, 134 

varieties of, 102 
Rheumatism, Heberden's, 103 

visceral diseases in, 103 
Rheumatism, nodular, 19, 38, 102 

arthropathies in, 135 

cardiac diseases in, 129 

erysipelas in, 133 

general symptoms of, 141 

in old subjects, 139 

in young subjects, 138 

mode of production of deformities in, 
140 

two forms of, 141, 142 

varieties of deformities in, 136, 437, 
138 
Rheumatism, partial chronic, 143 

characteristics of, 144 
Rheumatism, partial chronic articular, 103 
Rheumatism, subacute, duration of, 121 

endocarditis in, 128 

eye diseases in. 133 

pathological blood condition of, 121 

sciatic neuralgia in, 133 

trifacial neuralgia in, 133 

traumatic causes of, 152 

uterine functions in the etiology of, 
153 
Richardson, 99, 122, 173 
Rindtleisch. 106 
Ringer, 118 
Robin, 22, 97 
Rodier, 121 
Rohrig, 188 
Rokitansky, 15, 75 
Rollet, 152 
Romberg, 129, 135 
Roseau, 19 



Salpetriere Hospital, inhabitants of, 17 
internal organization of, 17 



Saturnismus in animals, 14 
Scheele, 41, 95 
Schelling, 15 
Scherer, 97 
Schlossberger, 22 
Schmidtmann, 59, 74 
Schnepf, 23 
School, anatomical, 10 

Viennese, 15 
Schoenlein, 15 
Schonlein, 72 
Schottin, 120 
Science, modern, 8 

the universality of, 16 
Scrofula, gout, and phthisis, 79, 80 
Scudamore, 64, 68, 75, 79, 86 
Secretions in old age, 23 
See, 14 
Seegen, 76 
Septicaemia and ammongemia, differential 

diagnosis of, 264 
Simon, 121, 185 

Skin, diseases of, in abarticular gout, 70 
Small-pox, hemorrhagic, 28 
Smith, 101 

Soda-urate, depositions of, 48 
Soda, urate of, in joints, 40 
Softening, acute cerebral symptoms of, 238 

atrophic cerebral, 237 
Softening, cerebral, 236 

and cerebral tumors, differential diag- 
nosis of, 239 

differential diagnosis, 239 

etiology of, 237 

morbid anatomy of, 236 

prognosis of, 239 

red, 236 

treatment of, 239, 240 

varieties of, 236 

white, 237 

yellow, 236 
Softening, chronic cerebral, 237 

symptoms of, 238 
Speck, 98 
Spinal cord, diseases of, in gout, 68 

rise in temperature, in lesions of, 182 
Spontaneity in the causes of gout, 86 
Stahlism, 5 
Stockhardt, 66 
Stokes, 66, 174 
Stomach, cancer of, 27 

catarrh of, 241 

changes in, in old age, 241 

gout in, 64 

gout in the, diagnosis of, 65 
Stosch, 75 
Stupor, gouty, 67 
Sydenham, 78, 84, 104, 121, 173 
Synocha, 31 

Syphilis in the gouty, 74 
Swammerdam, 30 



Taine, 6 

Temperature, extreme limits of, 160 
febrile, in nervous diseases, 179 



280 



INDEX. 



Temperature, high febrile, in old age, 160 

high, danger of, in old age, 170 

in old age, 24 

in pathological states of the aged, 169 

low febrile, in old age, 109 

mechanism of lowering the, 187-1£9 

medium febrile, in old age, 169 

normal, of old age, 16/ 

subnormal, 37 
Tetanus, elevation of temperature in, 1 79 
Thermometry, axillary, 37 4 

in old age, 168 
Thermometry, clinical, 30 

importance of, in old age, 166 
Thermometry, rectal, 37 

in old age, 168 
Thierfelder, 191 
Thompson, 72 
Thrombosis, experimental, 13 

marasmic, 225 
Todd, 51, 57, 59, 67-69, 119. 120, 122. 158, 

155, 159 
Tophi, 46, 48 

clinical characteristics of, 59, 60 

frequency of, 49 

locality of, 49 

seat of, 48 
Trastour. 129, 140, 149, 150 
Traube, 13. 30, 59 
Trousseau. 57, (54. 67, 127, 153, 158 
Tscheschichin, 188 
Tuberculosis, pulmonary, 27 
Tumors, cerebral, and cerebral softening, 

differential diagnosis of. 880 
Turpentine, in the goaty, 75 
Typhus, in the gouty, 74 
Typhus fever, 28 



Uraemia and apoplexy, differential diagno- 
sis of, 834 

UlSBmia and cerebral hemorrhage, differ- 
ential diagnosis of, 234 

Ubaldini, 43 

Uhle, 97 

Ulcer, atheromatosis, 224 

Urate of lithia, 101 

Uhl, 72 

Urethra, stricture of, and hypertrophy of 
the prostate, differential diagnosis of, 
201 

Urethritis, gouty, 70 

Uric acid, experimental production of, OS 
Olgmna in which, is formed. 07 
sources of, 96 



Uric acid diathesie, 55 
dyspepsia in, 55 



urine in, oo 



Urinary passages, diseases of, in gout, 69 
Urine, in acute gout, 43 

in chronic gout. 44 

retention of, and paralysis of the blad- 
der, differential diagnosis of, 250 



Valleix, 120 

Van Swieten. 13, 67. 84, 122, 173 

Veins, pulsation in, in old age, 885 

Verge, y, 106 

Vesalius, 3 

Y. -sels, changes in, in old age, 223, 224 

Vidal. 132. 1*9, 151 

Vigla, 68 

Vinmow, 18, 1''., 22 

Vitalism. 8 

Voisii, 

Von 15. rensprung, 167 

Vulpian, 18, 22 



Walah. 120 
Wardrop. 71 

i 65, 240 
Webb. 140 
Weber. 21. 185 
Weber. O . 105, 106 

;. 18 

120. 150 
Wertphal, 170 
Whvtt. 75 
Wiilemin. I 
Williams 122. 
Wiutrich. 23 
Wolff. 186 
Wollaston. 41 
Wunderlich, 80, 
191 



Xenophon. 151 
Yellow fever. 88 



Zalesky. 53, 97, 

experiments of, 53, 100 

Z. is. 105 
Ziemssen, 170 


















LIBRARY OF CONGRESS 



022 216 236 1 













